Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the enrollee is feeling symptomatic and could be at 
risk of having a stroke. You say that the enrollee needs to be evaluated to see how she should be treated. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or under this 
contract. 
 
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 an ILR. Our reviewer says that an ILR 
is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee 
had no history of atrial fibrillation. A recent randomized clinical trial found that continuous monitoring for 
atrial fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) 
was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke 
but without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be 
considered medically appropriate and necessary in this enrollees clinical management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on February 25, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network 
care. 
 
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 physician services provided on February 25, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames (V2020), bifocal lens (V2200), and progressive 
lens (V2781) provided on April 26, 2022. 
 
You asked the Plan to pay for the glasses. The Plan denied your request. The Plan says your benefit maximum 
has been met. The Plan also says that progressive lenses are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers lenses one pair of eyeglass frames every year on a rolling calendar year basis. 
 
 
 
 
 
 
 
 
 We looked at the file and the Plan's rules. The record shows that you last received a pair of glasses on May 25, 
2021, which exhausted your benefit through May 25, 2022. Based on this information, we decided that the 
Plan's rules for coverage of the glasses have not been met. Therefore, we decided that the Plan does not have to 
pay for the frames (V2020), bifocal lens (V2200), and progressive lens (V2781) provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on July 22, 2021. 
 
You asked the Plan to pay for the testing services. You say that the testing was necessary for the treatment of 
the enrollee's advanced cancer. The Plan denied your request. The Plan says a DEX Z-code is required. 
 
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 the test at issue was not billed as required. 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 FoundationOne testing provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heart monitor that is placed under the skin. 
 
You asked the Plan to pre-approve a heart monitor that is placed under the skin. You say that the records 
provided support the need for the requested device. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for coverage of an implantable loop recorder. 
 
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 a heart monitor that is placed under the 
skin. Our reviewer says that a heart monitor that is placed under the skin is not considered medically reasonable 
and necessary in this case. Our physician reviewer found there is no documentation provided to suggest a 
history of syncope or any other apparent indication for an ILR. There is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a heart monitor that is placed under the skin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heart monitor that is placed under the skin.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the transplant related lodging, meals and 
transportation (S9975) provided on April 27, 2022. 
 
You asked the Plan to reimburse you for the transportation services. You say that you would like to be 
reimbursed for the travel expenses for your appointment related to your possible lung transplant. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transportation services have not been met. Specifically, the file does not support that the appointment was related to a planned transplant. Therefore, we decided that the Plan does not have to 
reimburse you for the transplant related lodging, meals and transportation (S9975) provided on April 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot walk, get up to go to the bathroom, lift 
your neck or any part of your body. The Plan denied your request. The Plan says your clinical information has 
been reviewed and we have determined that coverage cannot be provided for inpatient medical rehabilitation 
level of 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 you were admitted to the hospital on August 23, 2022 for planned back surgery. 
You were discharged to a skilled nursing facility for inpatient rehabilitation services then re-admitted to the 
hospital on August 31, 2022 due to difficulty breathing. You were diagnosed and treated for pneumonia. Your 
dysphagia had worsened and required placement of a feeding tube. You were admitted to the hospital a third 
time on September 15, 2022, due to a possible infected wound and have remained medically stable. Recent 
therapy notes indicate that you are able to ambulate short distances using a walker and minimal assistance and 
require assistance with some of your self-care tasks. There are no complex nursing or rehabilitation needs. 
While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 36 skilled nursing visits in your home (G0299, G0300). 
 You asked the Plan to pre-approve home health services. You say that the skilled nursing visits are medically 
necessary. The Plan denied your request. The Plan says the requested services were not medically necessary. 
 
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 services. Our reviewer 
says that the home health services are not medically necessary. Our physician reviewer found the provided 
documentation does not indicate that you have skilled nursing needs. Therefore, the reviewer found that the 
requested home health services are 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 36 skilled nursing visits in your home (G0299, G0300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a static knee device. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the 
device is investigational. 
 
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 the requested device. Our physician 
reviewer found that in this case, the requested device is used for the knee. It is a bi-directional progressive 
stretch knee device with range of motion adjustment. The requested device has not been shown to be superior 
to other standard treatments for the medical condition. The studies do not indicate the static knee brace 
improves an individuals function or general health. Therefore, the requested device is 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 the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a static knee device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from October 8, 2021, to 
October 14, 2021. 
 You asked the Plan to pay for the inpatient services. The Plan denied your request. The Plan says the billed 
DRG is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code A41.9. 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 inpatient services. Our reviewer says that the use of diagnosis code 
A41.9 is not supported by the records provided. Our physician reviewer found that while the records include a 
physician-documented diagnosis of sepsis, and that Systemic Inflammatory Response Syndrome (SIRS) signs 
were present, along with an elevated lactic acid, the clinical findings in the record do not sufficiently support 
the diagnosis of sepsis based on Sepsis 3 criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from October 8, 2021, to October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with a Single Power 
Option (K0856), a power tilt system (E1002), and other accessories (E2613, E1225, E0956. E2607, E0953, 
E1012, K0040, E2377, E2313, E2361). 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with a Single Power Option, a power tilt 
system, and other accessories. You say that the enrollee is at high risk for pressure ulcers. The Plan denied your 
request. The Plan says the enrollee does not need any power options. 
 The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with Single Power Option (K0856) is 
covered if the beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity and the beneficiary either uses a ventilator which is mounted on the wheelchair or meets 
coverage criteria for a power tilt or power recline seating system. A power tilt or a power recline seating 
system will be covered if the enrollee is at high risk for development of a pressure ulcer and is unable to 
perform a functional weight shift; or the enrollee utilizes intermittent catheterization for bladder management 
and is unable to independently transfer from the wheelchair to bed; or the power seating system is needed to 
manage increased tone or spasticity. 
 
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 a Group 3 power wheelchair with a 
Single Power Option, a power tilt system, and other accessories. Our reviewer says that the specific power 
wheelchair requested is not medically necessary. Our physician reviewer found the documentation does not 
indicate that the enrollee has any pressure injuries or requires intermittent catheterization of the bladder that 
would necessitate power tilt or recline. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Group 3 power wheelchair with a Single Power Option, a power tilt system, 
and other accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with a Single Power Option (K0856), a power tilt system (E1002), and other 
accessories (E2613, E1225, E0956. E2607, E0953, E1012, K0040, E2377, E2313, E2361).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services coded 
99239 provided on August 9, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
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 code 99239 is hospital discharge day management; more than 
30 minutes. 
 
 We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge 
summary does not support hospital discharge day management of more than 30 minutes was performed. A 
documented time of 31 minutes or more is required to support this code. The documentation does not include 
the time spent on this service. Based on this information, we decided that Medicare rules for coverage of the 
hospital discharge day management services have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital discharge day management services coded 99239 provided on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for a podiatry visit on March 
28, 2022. 
 
You asked the Plan to waive the deductible and copayment for podiatry services. You say that nothing was 
done to relieve your foot pain, and you are unhappy with the procedure. You also say the bill is outrageous. 
The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan says the deductible 
was not met prior to the claim processing. The Plan also says that your concerns about the providers quality-
of-care was addressed in a separate grievance process. Contact the Plan for information regarding your quality-
of-care concerns. 
 
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 there is a $750 
deductible which applies to non-routine podiatry visits. Your contract also clearly says you must pay a $35 
copayment for each Medicare-covered podiatry visit. 
 The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit 
category Podiatry Services. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $750 deductible and a $35 copayment which applies to Podiatry Services. This cost sharing is a 
contractual obligation that had not been met at the time the podiatry visit was rendered on March 28, 2022. You 
have been asked to pay a $203.18 cost-share for a podiatry visit. You are required to pay for the entire service 
until your deductible is met. 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 deductible and copayment for a podiatry 
visit on March 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Current Procedural Terminology (CPT) code(s) 87798 (13 Units), 87641 (1 Unit), 
88305 (2 Units), and 88312 (6 Units) remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on October 
21, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you do not believe that 
COVID-19 testing has any charge through your Plan, and you should not have been billed a COVID-19 test 
copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $45 
copayment for each covered office visit to other providers for urgently needed services.  
 
You have been asked to pay a $45 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on October 21, 2021.