Persius/hicric huggingface dataset:
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 the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 you appear to be somewhat unstable and require additional short-term acute care 
services that can be safely administered at the current facility until more stable and appropriate for 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 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 lab services (81403, 81404, 81401) provided January 21, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service was for screening purposes and is non-covered. 
 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81403, 
81404, 81401) provided January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82310, 83970, 84100) provided January 4, 
2022. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services billed are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
lab services (82310, 83970, 84100) provided January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve healthy grocery services as part of special supplemental 
benefit for the chronically ill. 
 
You asked the Plan to pre-approve healthy grocery services. You say that healthy groceries are necessary for 
your medical condition, and you qualify for the Plan's supplemental program. The Plan denied your request. 
The Plan says the criteria for the healthy grocery supplemental benefit have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that healthy groceries are not covered by Medicare 
but are covered under the Plans supplemental benefit. The Plans contract specifies that you must have a 
chronic illness as listed by the Plan.  
 
We looked at the file and Medicare rules. Based on a review of medical records, you do not have a chronic 
illness that qualifies for the supplemental benefit. Based on this information, we decided that Medicare rules 
for coverage of healthy grocery services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve healthy grocery services as part of special supplemental benefit for the chronically ill.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion office visit to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a second opinion office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies (A4256) provided February 8, 2022 to 
April 28, 2022. 
 
You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of diabetic supplies (A4256) provided 
February 8, 2022 to April 28, 2022. have been met. Additional records were requested to support the number of units billed, but none were received. Therefore, we 
decided that the Plan does not have to pay for diabetic supplies (A4256) provided February 8, 2022 to April 28, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 4, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 5, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says the billed service cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
on November 5, 2021, have been met. In this case, the provider has not submitted the test results to indicate the 
services were performed as billed. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on November 
5, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 enrollee does not have the medical complexity to require the intensity of 
rehabilitation physician oversight provided in the acute inpatient rehabilitation setting and has not had a change 
in pre-existing medical conditions that require more frequent oversight or management. The enrollee does not 
require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy 
management or bowel and bladder 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 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: 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 appealing the denial of IRF admission. The 
Plan denied your request. The Plan says the record shows that you do not meet Medicare guidelines for services 
in an inpatient rehabilitation 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 you were admitted for respiratory failure and surgical management of an 
incarcerate hernia. Medical problems are stable. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 7, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi-precision abutment placement on tooth #22 and 27 
(D6191), semi-precision attachment placement on tooth #22 and 27 (D6192), implant supported removable 
denture (D6111), and an unspecified removable prosthodontics procedure (D5899). 
 
You asked the Plan to pre-approve the dental services. You say that you needed two implants so you could get 
bottom dentures. The Plan denied your request. The Plan says semi-precision abutment placement (D6191), 
semi-precision attachment placement (D6192), implant supported removable denture (D6111), and an 
unspecified removable prosthodontics procedure (D5899) are not covered by your routine dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
semi-precision abutment placement on tooth #22 and 27 (D6191), semi-precision attachment placement on 
tooth #22 and 27 (D6192), implant supported removable denture (D6111), and an unspecified removable 
prosthodontics procedure (D5899).
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 appealing the denial of admission to an IRF. 
The Plan denied your request. The Plan says based on review of the enrollees medical information they do not 
meet Medicare criteria for admission to an IRF. 
 
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 enrollee was admitted for anemia and a fall. Medical problems are stable. 
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 inpatient rehabilitation facility (IRF) admission and services.
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days 
a week, or 15 hours over seven consecutive days. You may benefit from physical and occupational therapy but 
do not need the intensity of these therapies provided in the acute inpatient rehabilitation setting. 
 
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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. The enrollee has had a functional decline 
relative to baseline level of function and can benefit from physical therapy and occupational therapy, but it is 
not clear that the enrollee can tolerate the intensity of therapy provided in the acute inpatient rehabilitation 
setting. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture sessions. 
 
You asked the Plan to pre-approve additional acupuncture sessions. You say that the services are necessary. 
The Plan denied your request. The Plan says the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have exhausted your 20 acupuncture sessions for 
the year. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture sessions.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 1, 2021 billed with 
codes 81206 and 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 1, 2021 billed with codes 81206 and 81292.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of breast localization device (19281) provided 
on August 26, 2021. 
 
You asked the Plan to pay for the placement of breast localization device. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this code has not 
been billed appropriately per Medicare coding guidelines.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 19281 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
placement of breast localization device have not been met. Therefore, we decided that the Plan does not have to 
pay for the placement of breast localization device (19281) provided on August 26, 2021.