Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92004) provided on February 
21, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmological services. You say that the services were rendered at a 
nursing and rehabilitation center. You also say that the services provided should be covered under the 
authorization number that the facility received. The Plan denied your request. The Plan says the services were 
rendered by an OON provider. The Plan also says that authorization was not obtained prior to the services 
being rendered. 
 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 ophthalmological services (92004) provided 
on February 21, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PCP services to be rendered by a specialist. 
 
You asked the Plan to pre-approve the PCP services. You say that this provider is the director for the same 
building you live in. The Plan denied your request. The Plan says this provider is specialist, not a PCP. The 
Plan must follow Medicare rules. We looked at the file and Medicare rules. This provider is a Plan preferred 
network as a specialist, and they are not contracted as a network PCP. Therefore, we decided that the Plan does 
not have to pre-approve PCP services to be rendered by a specialist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 18, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says medical 
necessity has not been established. 
 The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and the rules. We find that the testing at issue is not supported in the medical record. 
Specifically, the records do not show that the enrollee has 1-3 positive nodes. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on February 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift elevation system. 
 
You asked the Plan to pre-approve a power seat lift elevation system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that you are requesting a power seat 
elevation system. This item is specifically not covered. Based on this information, we decided that Medicare 
rules for coverage of a power seat lift elevation system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat lift elevation system.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1, BRCA2 (breast cancer 1 and 2) test (81162) to 
be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the laboratory services. You say that the records provided support the 
necessity of the service in dispute. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
BRCA1, BRCA2 (breast cancer 1 and 2) test (81162) to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to approve computerized dynamic posturography (92548, 92549). 
 
You asked the Plan to approve computerized dynamic posturography. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this service is considered experimental/investigational, 
and therefore is not covered. 
 
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 pre-approve computerized dynamic posturography. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is insufficient evidence in the medical literature to support the 
use of Computerized Dynamic Posturography in the evaluation of sensorineural hearing loss, dizziness and 
giddiness. The documentation does not support that Computerized Dynamic Posturography is medically 
reasonable and necessary for the enrollee in this case, or that it is an accepted standard of medical practice that 
would impact the enrollee's management and outcome. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computerized dynamic posturography have not been met. Therefore, we decided 
that the Plan does not have to approve computerized dynamic posturography (92548, 92549).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab/testing services billed with procedure codes 76981, 
87522 and 80320 for date of service January 25, 2022. You asked the Plan to pay for lab/testing services. You say that these services were billed correctly and are 
supported in the medical record. The Plan denied your request. The Plan says the payment for codes 76981 and 
87522 is bundled into payment for code 94664. Therefore, separate payment for these services cannot be made. 
Also, code 80320 is not recognized for Medicare purposes. Medicare uses a different billing code for this 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
 
Although we could not find evidence that 87522 or 76981 a column II code to 94664, nor were we able to find 
evidence that 94664 was billed for this enrollee by the provider on the date in question, we have confirmed that 
code 87522 is a column II code to column I code 87521, which was billed on this same claim. We have also 
confirmed that 76981 is a column II code to column I code 76705, which was also billed on this same claim. 
These claim lines have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
In addition, we find that CPT code 80320 has a Status Indicator of I on the Physician Fee Schedule. This means 
that CPT code 80320 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of 80320 have not been met. Therefore, we decided that the Plan does not have to pay for 
lab/testing services billed with procedure codes 76981, 87522 and 80320 for date of service January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stair glide (stair lift) received on July 31, 2020. 
 
You asked the Plan to pay for a stair glide. You say that you disagree with the plan's denial. The Plan denied 
your request. The Plan says the item received is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for the stair glide (stair lift) received on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF services is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's condition does not meet Medicare requirements for 
admission to IRF. The enrollee can receive care in another setting such as a skilled nursing facility, outpatient 
setting, or home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. 
 
At the current functional level, the enrollee does not need intensive therapies consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach in an IRF. IRF admission is not 
medically necessary based lack of medical complexity and acute rehabilitation nursing needs and high 
functional level. 
 
Documentation does not support the medical necessity for admission to an IRF. While the enrollee may benefit 
from continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on February 17, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that prior to making the appointment, you called and 
was told by the office staff that they did take your insurance. They never mentioned that they were out of 
network so you were surprised to learn this when you received the EOB. The Plan denied your request. The 
Plan says enrollees must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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 outpatient office visit (99214) provided on 
February 17, 2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like to request 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the member is 
receiving appropriate in-patient acute care and does not require transfer to a 
long-term acute care hospital (LTACH). 
 
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 Based on the documentation provided, it is my opinion that the health plans denial 
of LTACH coverage should be upheld.  The patient is currently undergoing treatment at an ACH for a back 
wound/abscess.  The enrollee is not intubated/ventilated.  There is no evidence that the enrollee requires 
services that are not currently available.  As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH 
until such time no acute services are required.  The enrollee can then be transferred/discharged to a lower level 
of care for any ongoing LTC needs.  
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on March 17, 
2021. You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on March 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen concentrator (CPT code E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that it is medically unsafe for 
your oxygen levels to drop below 90. You state that you sleep with oxygen and need oxygen available to you at 
all times. You state the equipment you have furnished to you does not adequately meet your medical needs to 
live your life. The Plan denied your request. The Plan says they do not cover duplicate or redundant durable 
medical equipment such as oxygen device when the second item performs the same function as the one 
currently provided to you. There is no medical documentation to support your need for a portable oxygen 
concentrator. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. The file shows that you have an oxygen device. an oxygen device serves the same 
purpose as the portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve 
portable oxygen concentrator (CPT code E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home COVID test kits you purchased on January 17, 
2022. 
 
You asked the Plan to pay for the test kits. The Plan denied your request. The Plan says this is not 
reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that up to eight COVID-19 tests are covered each 
month. The tests covered under this initiative will be covered outside of your existing plans coverage.  
 
We looked at the file and Medicare rules. In this case, the requested COVID home test kits are covered through 
Original Medicare. You would have needed to use your Original Medicare card at the time of purchase to 
receive the test kits from a participating provider. Based on this information, we decided that Medicare rules 
for coverage of the test kits have not been met. Therefore, we decided that the Plan does not have to pay for the 
home COVID test kits you purchased on January 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional physical therapy sessions are 
medically necessary. The Plan denied your request. The Plan says the criteria for additional physical therapy 
has not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee is able to walk 2 miles with mild discomfort. Further 
physical therapy is unlikely to yield significant improvement in the enrollees pain level and function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy sessions provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on December 13, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the place of 
service is not appropriate for the code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
 We find that CPT code 85060 was billed with a place of service code 22, an on-campus outpatient hospital. No 
payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the pathology services provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) 
services you are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found Based on the documentation provided, it is my opinion that the health plans denial should be upheld.  The enrollee does not require the intensity of services provided at an IRF.  Specifically, the 
enrollee is not shown to require, or currently to be able to tolerate, fifteen hours per week of rehabilitative 
services and regular physician evaluation.  The enrollees care needs can be met at a lower level of care (ex. 
SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Ensure. 
 
You asked the Plan to pre-approve the Ensure. You say that you want the supplement Ensure covered. The Plan 
denied your request. The Plan says nutritional supplements are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the Ensure.