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

 
We decided that the Plan does not have to pay for the lab services provided on January 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the specimens are received from providers and are 
irreplaceable. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
 The Plan must follow Medicare rules. Medicare rules say that 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. 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 January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device 
(E0601) and supplies purchased on August 31, 2021. 
 
You asked the Plan to pay for a CPAP device and supplies. You say that the requested items are a necessity for 
your care. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules provide only for rental of CPAP devices and accessories. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a CPAP device and supplies have not been met. Specifically, you have purchased rather than 
rented the items at issue. Therefore, we decided that the Plan does not have to pay for a continuous positive 
airway pressure (CPAP) device (E0601) and supplies purchased on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transthoracic echocardiography (TTE) (93308) provided 
on September 28, 2021. 
 
You asked the Plan to pay for the TTE (93308). You say that the patient went to the emergency room and was 
seen by the physician for a medically necessary procedure. You say that the claim should be reprocessed to pay 
the procedure. The Plan denied your request. The Plan says the provider did not submit a valid ICD- 10-CM 
diagnosis code. 
 
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 the TTE (93308). Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no supportive evidence for the medical necessity of TTE in the 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 the TTE (93308) have not been met. Therefore, we decided that the Plan does 
not have to pay for the TTE (93308) provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services (CPT code 99214) to be provided by 
a tertiary care provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have been going for treatment 
for two (2) years, and this provider is advanced in the care of your cancer which immune thrombocytopenia 
(IPT). The Plan denied your request. The Plan says you have been going for treatment for two (2) years, and 
this provider is advanced in the care of your cancer which immune thrombocytopenia (IPT). 
 
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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network services. Our physician reviewer found the review 
indicates that the enrollee can be managed in Plan. There is no specific indication for continued out-of-network 
services. The review has determined that the services do not need to be provided by a tertiary care provide. The 
services can be performed in-network. 
 
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 out-of-network services have not been met.  
 
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 the out-of-network services. Therefore, we decided 
that the Plan does not have to pre-approve the office services (CPT code 99214) to be provided by a tertiary 
care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device provided on July 6, 2021. 
 
You asked the Plan to pay for the provided services. The Plan denied your request. The Plan says the claim was 
billed with an invalid code. 
 
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 CPT code A9279 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the provided services have not been met. Therefore, we decided that the Plan does not have to pay 
for the monitoring device provided on July 6, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on October 19, 2021. 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says that this testing is unlikely to impact therapeutic decision-making in the clinical 
management of the patient and will be denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 
necessary and meet the applicable coverage criteria. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a gastrointestinal stromal tumor of the small intestine, stage IV. Genetic testing was 
ordered to help choose more effective personalized treatment for her condition. The NCCD guidelines support 
the use of genetic testing for those with advanced cancers. This patient would benefit from this testing and it 
will be considered medically reasonable and 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 services have been met. Therefore, we decided that the Plan has to pre-
approve laboratory services provided to the enrollee on October 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member is unlikely able to participate in an intensive therapy 
program of three hours of therapy a day at least 5 days a week. 
 
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and 
hypertensive urgency. The enrollees medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need 
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips. 
 
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that you do not 
have any way to get to the facility on May 13, 2022. The Plan denied your request. The Plan says the requested 
amount exceeds the limit listed by the plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. The mileage you are requesting is 
eighty-eight (88) miles over your allowed benefit. Your 2022 EOC states up to sixty (60) one-way trips are 
covered each year (limited to ground transportation only). Each one-way trip must not exceed seventy-five (75) 
miles of driving distance. A trip is one-way transportation; a round trip is two (2) trips. Therefore, we decided 
that the Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Waterpik flosser, humidifier, foot bath massager, bag 
balm (skin moisturizer) and back brace purchased from September 24, 2021, to December 5, 2021. 
 
You asked the Plan to pay for the purchased items. You say that these items are wellness related and you would 
like your health and wellness benefit to cover these items instead of a gym membership. The Plan denied your 
request. The Plan says these items are not covered by Medicare or by your supplemental benefit. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  Though the Plan offers a supplemental benefit in excess of Medicare coverage, the requested items/services are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
Waterpik flosser, humidifier, foot bath massager, bag balm (skin moisturizer) and back brace purchased from 
September 24, 2021, to December 5, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department services provided on December 
15, 2021. 
 
You asked the Plan to pay for the services provided. You say that all codes were correctly coded. The Plan 
denied your request. The Plan says the appropriate modifier was not appended to 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 looked at the file and the rules. The records show that the enrollee was incarcerated at the time the services 
were provided. The claim does not show that a modifier was billed per guidelines. 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 emergency department services provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost-share for the specialist office visit (99213) provided on October 
29, 2021. 
 
You asked the Plan to waive the cost-share for the specialist office visit. You say that you are being billed 
unfairly for these services, and you were told that they would still be covered even though your provider does 
not accept your plan. The Plan denied your request. The Plan says that this claim was processed correctly, and 
your cost-sharing was assessed in accordance with your contract.  
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $50 copayment for each Medicare-covered specialist visit 
received from an in-network provider, or 30% coinsurance for each Medicare-covered specialist visit received 
from an out-of-network provider. 
 
The Plan says you must pay a $50 copayment for the specialist office visit. However, the Explanation of 
Benefits and the submitted claim information support that the rendering provider in this case is out-of-network. 
In this case, the Plans cost-share for an out-of-network specialist visit is less than the in-network copayment. 
The Plans allowed cost for this service is $94.51, which means that the out-of-network coinsurance is less than 
the in-network copayment that has been assessed ($94.51 x 30% coinsurance = $28.29). Based on the Plan 
contract, you cannot be asked to pay more than $28.29 for the specialist office visit in question, which was 
rendered by an out-of-network provider. Therefore, we decided that the Plan has to reduce the cost-share for 
the specialist office visit (99213) provided on October 29, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
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 had a leg amputation, and you cannot walk, 
move or do anything on your own without assistance. You state if you go home after surgery that you will be 
left without care and will be stuck in one spot without any assistance. The Plan denied your request. The Plan 
says the stay is not medically necessary based on IRF criteria. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an 
infection of the right leg and had a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a 
need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you could be treated safely and 
effectively at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is 
not expected you would improve in a reasonable period of time as you are not showing any dangerousness to 
self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute 
threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the 
acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal 
thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your 
condition does not meet criteria for coverage of inpatient psychiatric 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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided September 28, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you were not provided this enrollee's correct 
diagnosis codes for the date of service until timely filing limit had expired. Please reprocess the claim based on 
the provided information. The Plan denied your request. The Plan says the claim was submitted past the timely 
filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for laboratory services was not filed until December 27, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no definitive evidence that this monitor has been established a standard of care 
for improved congestive heart failure or cardiac outcomes. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and 
consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure 
in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval 
was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the 
CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was 
somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in 
heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device for the enrollee.