Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing, occupational therapy, and 
home health aide visits. 
 
You asked the Plan to pre-approve home health visits. You say that you are appealing with records. The Plan 
denied your request. The Plan says the denial of authorization for additional home health visits is correct.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve home health visits. Our reviewer says 
that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found 
the documentation does not support that you require additional skilled nursing services or skilled rehabilitation 
services to provide treatment that is medically necessary. You do not require additional skilled nursing or 
rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition 
or perform a maintenance program. You have been medically stable without any recent exacerbations of 
chronic medical problems or hospitalizations. You do not require the services of a home health aide and the 
approved visits should be sufficient to establish a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve home health skilled nursing, occupational therapy, and home health aide visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the arthrocentesis and hyaluronan injection
provided on May 7, 2021, May 14, 2021, and May 21, 2021.

You asked the Plan to waive the cost for the arthrocentesis and hyaluronan injection. You say that you are
disputing the cost. The Plan denied your request. The Plan says the cost share applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for services obtained from a specialist and 20% coinsurance for each Medicare-covered Part B
drug.

You have been asked to pay a total of $192.42 for the arthrocentesis and hyaluronan injection.

The arthrocentesis falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit
category. The hyaluronan injection falls within the "Medicare Part B Prescription Drugs" benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost for the arthrocentesis and hyaluronan injection provided on May 7,
2021, May 14, 2021, and May 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 12, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the provider did not 
submit all of the necessary medical records. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure codes 75710 and 75625) provided to the enrollee on May 17, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of the denied codes: 

CPT 75710: 

Angiography, extremity, unilateral, radiological supervision and interpretation 

CPT 75625: 

Aortography, abdominal, by serialography, radiological supervision and interpretation

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that in terms of CPT 75710, the documentation does not support an angiography was performed on any other area, other than the where the primary procedure was performed. Therefore, this procedure would be inclusive to the primary procedure reported. In terms of CPT 75625, the documentation does not show an angiography was performed in abdomen; therefore, this procedure cannot be confirmed as performed. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure codes 75710 and 75625) provided to the enrollee on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit and laboratory services 
provided on July 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hospital outpatient clinic visit and laboratory services. You say that you 
would like this claim to be reconsidered for payment. The Plan denied your request. The Plan says these 
services were rendered by an OON provider and were not referred by a network provider or in a participating 
facility. The Plan also says that these services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit and laboratory 
services provided on July 26, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the capsule endoscopy (91110) provided on April 19, 2021.

You asked the Plan to pay for the capsule endoscopy. You say that the service was medically necessary. The Plan denied your request. The Plan says the provided documentation does not show that the capsule endoscopy was medically necessary.

The Plan follows Medicare rules. Medicare rules say that the medical record documentation must support the medical necessity. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the capsule endoscopy. Our reviewer says that the capsule endoscopy is not medically necessary. Our physician reviewer found the provided documentation does not support that the coverage criteria have been met in this case. The reviewer found that there is no documentation that indicates the enrollee has undergone upper gastrointestinal endoscopy and colonoscopy, which have failed to reveal a source of bleeding. Therefore, the reviewer found that the criteria for coverage has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the capsule endoscopy have not been met. Specifically, the file does not show that the enrollee has undergone upper gastrointestinal endoscopy and colonoscopy, which have failed to reveal a source of bleeding. Therefore, we decided that the Plan does not have to pay for the capsule endoscopy (91110) provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee needs to remain in the hospital to complete a full course. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine PCR panel testing provided on March 29, 2021. 
 
You asked the Plan to pay for urine PCR panel testing. You say that the services rendered were required by the 
ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because the standard of care is urinalysis with urine culture and sensitivity and this testing is 
considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for urine PCR panel testing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the standard of care for the evaluation of the enrollee's condition is urinalysis with 
urine culture. This testing is considered unproven and not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of urine PCR panel testing have not been met. Therefore, we decided that the Plan 
does not have to pay for urine PCR panel testing provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on May 21, 2021.
You asked the Plan to pay for the hearing aids. You say that you were told you could go to any in-network or
out-of-network provider. You say that you went to this provider because they were cheaper, and you couldn't
afford them anywhere else. The Plan denied your request. The Plan says there is no authorization for out-ofnetwork
services.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are received from a network provider.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Specifically, the hearing aids were received from an out-ofnetwork
provider. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on
May 21, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.

You asked the Plan to pay for inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. The record indicates that you are scheduled for a total knee arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on June 30, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has stage IV adenocarcinoma of the left lung, metastatic to the pleura and peritoneum. The documentation does not support that tissue-based, comprehensive genomic profiling (CGP) is infeasible or that NSLC Tissue-based CGP has shown no actionable mutations. The documentation does not support that it was reasonable and medically necessary for the enrollee to have the Guardant360 testing in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) and ground mileage (A0425) provided June 14, 2021. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you did not give consent 
for the ambulance to be called and would like the copayment removed. The Plan denied your request. The Plan 
says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance service. The ambulance service falls within
the Ambulance services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage (A0425) 
provided June 14, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says medical needs can be met in a lower level of care, such as at home with outpatient therapy or long term care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure codes 81227, 81226, 81225, 81223) provided to the enrollee on May 6, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a single code should be reported with expanded pharmacogenomic panels.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure codes 81227, 81226, 81225, 81223) provided to the enrollee on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 29, 2021.

You asked the Plan to pay for the dental services. You say that in the 2021 Annual Notice of Changes there is no mention of the dentist being disqualified from coverage. You say that services from this dentist were covered last year. You also say that you were not informed of this change. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to dentists that have opted out of Medicare.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, dental services received from a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and purchase of 
two half leg appliances (E0673), provided on April 12, 2021 
 
You asked the Plan to pay for intermittent limb compression device. You say that this item was medically 
necessary. The Plan denied your request. The Plan says this item was used during surgery as a preventative 
measure. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous 
stasis ulcers. The item was used during surgery to prevent deep venous thrombosis. This means the item is not 
covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) 
and purchase of two half leg appliances (E0673), provided on April 12, 2021 .