Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient hospital care provided from  
February 19, 2022, through March 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the inpatient hospital care provided was not 
medically necessary. 
 
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 these services. Our reviewer says that the 
continued inpatient hospital care provided was not medically reasonable and necessary.  Our physician reviewer found that according to the medical records provided, the enrollee was medically stable 
for discharge at this time but her disposition was complicated by psychosocial issues. There is no evidence that 
inpatient services were required.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued inpatient hospital care provided from February 19, 2022, through March 20, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve home health aide services. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that there is not a need for medical care in the home 
from a nurse or therapist. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our 
reviewer says that home health aide services are not medically reasonable and necessary. You are not receiving 
any skilled home health nursing or therapy services to qualify for home health aide services and records do not 
document that you are homebound. There is no documentation that the home health aide services are 
reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. Our physician reviewer found that your condition does not meet Medicare criteria for home health aide 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 home health aide services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve home health aide services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (28261) provided on January 24, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 28261 is "Capsulotomy, midfoot; with tendon 
lengthening". 
 
We asked our coder 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 services. Our reviewer says that the use of code 28261 is 
not supported by the records provided. Our reviewer found that the description of this procedure was captured 
in another CPT code that was billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (28261) provided on January 24, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal x-ray (74018) provided on May 18, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service should be reprocessed and paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on May 11, 2022. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the abdominal x-ray 
(74018) provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you cannot walk without the insoles. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and associated accessories. 
 
You asked the Plan to pre-approve a power wheelchair and associated accessories. You say that this power 
wheelchair is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file includes progress notes dated July 26, 2022, that confirms that the enrollee was ambulating without the 
use of assistive equipment. The evidence submitted does not support that the enrollees condition would not be 
ameliorated by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and 
associated accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services: medical examination and 
evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established 
patient, 1 or more visits, and Fundus photography provided on April 4, 2022. 
 
You asked the Plan to pay for ophthalmological services and Fundus photography. The Plan denied your 
request. The Plan says 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 Plan says that the Plan has also determined 
that these services are not urgent or emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, 
with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or 
more visits, and Fundus photography provided on April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found documentation does not support actual formal surgical ablation of pre-designated 
basivertebral nerves as being medically necessary and/or reasonable at this time. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested Intracept intraosseous basivertebral nerve ablation at L3-4 and L4-5, in this 
case, is not medically reasonable or 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
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 genicular artery embolization. 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 literature to establish the safety and efficacy of the 
requested service for the enrollee specific clinical condition at this time. The record provided does not establish 
the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements 
of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on March 7, 2022. 
 
You asked the Plan to pay for the services provided. You say that the test identifies bladder cancer tumors. The 
Plan denied your request. The Plan says that code 0012M is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The CxBlader test was billed using code 0012M. The Plan states the code at 
issue is non-covered based on a ruling from 2018. The updated ruling shows that the test is covered based on 
reasonable and necessary guidelines. The Plan offered no other rationale for denial. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for the lab testing services provided on March 7, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services (19370) provided on December 3, 2021. 
 
You asked the Plan to pay for procedure code 19370. You say that the medical records support the billing of 
code 19370. The Plan denied your request. The Plan says the medical records do not support the billing of code 
19370. 
 
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 19370 is Revision of peri-implant capsule, breast, 
including capsulotomy, capsulorrhaphy, and/or partial capsulectomy. 
 
We asked our coder 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 procedure code 19370. Our reviewer says that the medical 
records do not support the billing of code 19370. Our reviewer found the record indicates that the enrollee had 
bilateral tissue expanders removed and replaced with permanent implants. The provided record does not 
describe CPT code 19370. The elements of the coverage criteria are not satisfied. The requested service is not 
recommended.  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 19370 have not been met. Therefore, we decided that the Plan 
does not have to pay for the surgical services (19370) provided on December 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81292, 81295, 81297, 81298). 
 
You asked the Plan to pre-approve genetic testing. You say that medical records have been submitted to 
support the medical necessity for genetic testing. The Plan denied your request. The Plan says the requested 
testing can only be approved for people with symptoms of the condition being tested. Testing unaffected 
individuals is not a covered benefit. The enrollee does not meet criteria for approval. 
 
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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee in this case does not have a personal history or family history of a known germline 
pathogenic variant in a colorectal polyposis or cancer gene, and there is not a documented personal or family 
history of 10 or more adenomatous polyps, 2 or more hamartomatous polyps, or 5 or more serrated 
polyps/lesions proximal to the rectum. There is not a personal or family history of a Lynch syndrome-related or 
a personal history of a tumor with deficient mismatch repair. In addition, the enrollee does not have a 
documented cancer diagnosis that would qualify for coverage of genetic testing for an inherited mutation under 
Medicare. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing (81292, 81295, 81297, 81298).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and administration 
(90471) provided on June 16, 2022. 
 
You asked the Plan to pay for the vaccine. You say that you do not know how vaccines are covered. You also 
say that you feel you should not be responsible for this bill. The Plan denied your request. The Plan says the 
vaccine you received, and the administration cost is covered not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
 
 
 
 
 
 Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine (90750) and 
administration (90471) provided on June 16, 2022.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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 you. Our physician reviewer found 
clinical documentation shows that you have many uncontrolled comorbidities, below the knee amputation 
(BKA) is a compliant diagnosis and you would continue to require close medical monitoring on an inpatient 
basis during rehabilitation. Evaluating therapists recommend intense physical and occupational therapy. Thus, 
IRF criteria have 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 clinical documentation shows that you are currently being medically monitored in the 
outpatient setting through home health nursing thus, would not be expected to require inpatient hospitalization for close medical supervision. Clinical documentation shows that you have functional impairments but stated 
that progress is being made with home health skilled therapy and there is no documentation that you require 
intense therapy. Thus, IRF criteria have not been met and 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 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.