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

 
We decided that the Plan does not have to pay for the pharmacogenomics testing panel provided on January 17, 
2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no 
documentation how the results will impact treatment. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Medications should be provided based on the presence of a diagnosis 
and should be adjusted based on a response to the medication. In this case, there are no records from the 
treating physicians regarding medication response. Furthermore, the testing panel was not billed with a single 
code 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 pharmacogenomics testing 
panel provided on January 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99239 billed for date of service September 17, 2021. 
 
You asked the Plan to pay for code 99239. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this code is not supported in the medical records. 
 
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 Services; 
more than 30 minutes. Because this is a time-specific code, there must be documentation of the number of 
minutes spent with the patient on this service.  We looked at the records in this case and the records do not 
document the number of minutes spent on this service. That is why we find that CPT code 99239 is not 
supported in the medical record. Based on this information, we decided that Medicare rules for coverage of code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for code 99239 billed 
for date of service September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel acute inpatient rehabilitation is medically 
necessary. The Plan denied your request. The Plan says that rules for IRF care have not been met. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that the enrollee's active comorbidities and hospital complications thus 
continues to require close physician monitoring on an inpatient basis in an IRF. Although diagnosis is not IRF 
compliant evaluating therapists recommend intense therapy thus IRF criteria has been met and is 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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 are requesting inpatient rehabilitation for the 
enrollee to regain maximum function. The Plan denied your request. The Plan says rules for IRF care have not 
been met. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vasectomy. 
 
You asked the Plan to pre-approve a vasectomy. You say that this procedure is necessary for the enrollee. The 
Plan denied your request. The Plan says this procedure is statutorily not covered for the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that an elective vasectomy if the primary indication 
for these procedures is sterilization is not covered by Medicare. Based on this information, we decided that 
Medicare rules for coverage of a vasectomy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a vasectomy.
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 you are having difficulty doing things on your own 
and you are in need of IRF services. The Plan denied your request. The Plan says the enrollee's current medical 
stability and lack of medical complexity, there is no need for physician supervision 3 times per week for the 
ongoing management of any active or acute exacerbation of chronic medical conditions. The enrollee's current 
level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily 
therapy. The medical records do not support the need for an intensive rehabilitation therapy program consisting 
of at least 3 hours of therapy per day at least 5 days per week. The enrollee's ongoing skilled therapy and 
nursing needs can be provided at a lower level of care such as at a skilled nursing facility. 
 
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 in this case, the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this individual will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an inpatient rehabilitation facility. 
 
The enrollee continues to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that they would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain their functional status. The enrollee can 
receive further services at a lower level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on April 
14, 2022. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the inpatient 
claim. The Plan denied your request. The Plan says the claim was billed with an inappropriate place of service. 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 enrollees claim information shows that they were an outpatient at the 
time the services at issue were provided. The records do not include a physician order to admit the enrollee as 
an inpatient. 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 evaluation and management services provided 
on April 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (33285). 
 
You asked the Plan to pre-approve the implantable loop recorder. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that an Implantable Loop Recorder is used when syncope 
is thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or a traditional 
pre-symptom loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the implantable loop recorder is not medically necessary. Our physician reviewer found 
there is no documentation provided to suggest a history of unexplained syncope, or any other indication for this 
device. 
 
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 implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder (33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the test is not considered a hospital outpatient 
service. The Plan denied your request. The Plan says the codes must be reported with modifier 26. 
 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 claim information does not show that a modifier was billed to indicate 
the professional or technical of the services at issue. 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 December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic evaluation (D0120), bitewing x-rays 
(D0272), and prophylaxis (D1110) provided on January 31, 2022, and a restoration (D2392), porcelain crown 
(D2740), and core buildup (D2950) provided on March 28, 2022. 
 You asked the Plan to pay more for the dental services. You say that you were told your provided was in-
network. The Plan denied your request. The Plan says the crown and core buildup are not covered under your 
supplemental dental benefit. The Plan says the evaluation, x-rays, prophylaxis, and restoration were received 
from an out-of-network provider and were processed correctly.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the crown and core buildup are not 
among those covered under this benefit.  
 
The record shows the provider of these services was out-of-network with the Plan. You have been asked to pay 
the difference between the out-of-network providers charges and the Plans payment for the evaluation, x-rays, 
prophylaxis, and restoration. 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 pay more for a periodic evaluation (D0120), bitewing x-
rays (D0272), and prophylaxis (D1110) provided on January 31, 2022, and a restoration (D2392), porcelain 
crown (D2740), and core buildup (D2950) provided on March 28, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit on March 10, 
2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were told you 
would not receive a bill for this. The Plan denied your request. The Plan says the cost share has been 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 $90 
copayment for Emergency Care.  
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency Care 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 
emergency room visit on March 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft in conjunction with periradicular surgery 
(D3428). 
 
You asked the Plan to pre-approve a bone graft. You say that you are in pain and would like to appeal this 
service. The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft in conjunction with periradicular surgery (D3428).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided May 
14, 2022. 
 
You asked the Plan to pay for the dental services. You say that this service was necessary to correctly install 
abutments and crowns. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service May 5, 2021. Therefore, 
we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided May 14, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266) and the provision of 
drugs for home use (D9630). 
 
You asked the Plan to pre-approve tissue regeneration and the provision of drugs. You say that these services 
are medically necessary. The Plan denied your request. The Plan says that guided tissue regeneration (D4266) 
and the provision of drugs for home use (D9630) are not covered by the enrollee's dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration (D4266) and the provision of drugs for home use (D9630).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-home blood draw/test. 
 
You asked the Plan to pre-approve an in-home blood draw/test. You say that your handbook states that you are 
eligible for in-home services. You say that you have a condition that keeps you from going out and you do not 
want to get COVID-19. The Plan denied your request. The Plan says an in-home blood draw/test is 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 an in-home blood draw/test. Our 
reviewer says that an in-home blood draw/test is not medically necessary. Our physician reviewer found that 
based on the medical records provided there is no documentation that skilled nursing services are required to 
effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration. Provided records do not 
document any skilled nursing needs; a simple phlebotomy is not a skilled nursing need. The records do not 
document that you are home bound.  
 
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 in-home blood draw/test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an in-home blood draw/test.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (80307) provided on August 31, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service is supported in the medical record and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
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 (80307) provided on August 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for ambulance transportation January 24, 
2022, to February 5, 2022. 
 
You asked the Plan to waive the copayments for ambulance transportation. You say that the enrollee should not 
be responsible for this copayment. The Plan denied your request. The Plan says the copayment has been 
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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $265 copayment per date of service regardless of the number of trips enrollees for in-network 
Ambulance Services.  
 
 
 
 
 The enrollee has been asked to pay $530 ($265/trip x 2) for ambulance transportation. Ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayments for ambulance transportation January 24, 2022, to February 5, 2022.