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

 
We decided that the Plan does not have to pay for medical services provided on October 14, 2021. 
 
You asked the Plan to pay for the medical services. You say that this service should be covered and your 
organization would like to be considered in-network. The Plan denied your request. The Plan says the patient 
was enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve a partial psychiatric hospitalization. The Plan denied your request. The Plan 
says there is no evidence of homicidal risk or suicidal risk, and the enrollee can be safely managed on an 
outpatient basis with increased frequency of visits with their psychiatrist. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a partial psychiatric hospitalization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this enrollee was not showing any dangerousness to self or others and has 
not been exhibiting severe psychological or psychiatric impairment requiring this level of care. The enrollee 
was not showing any perceptual disturbance, psychosis or aggressive behaviors. Our reviewer also found that it 
does not appear medically necessary and reasonable to have psychiatric care provided at the partial 
hospitalization level of care rather than 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 a partial psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a partial psychiatric hospitalization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient consultation services billed with code 99253 for 
date of service November 11, 2021. 
 
You asked the Plan to pay for code 99253. You say that the medical records support payment for this code. The 
Plan denied your request. The Plan says Medicare does not pay for consultation codes. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 1, 2010, consultation codes 
(ranges 99241-99245 and 99251-99255) are no longer recognized for Medicare Part B payment.  The code you 
billed falls within the consultation code range, so this code is not payable. Therefore, we decided that the Plan 
does not have to pay for the inpatient consultation services billed with code 99253 for date of service 
November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided on March 28, 2022. 
 
You asked the Plan to pay for the services provided. You say that the claim was for the processing and analysis 
of the specimen. The Plan denied your request. The Plan says the code has a PC/TC indicator of 1. 
 
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 88305 is tissue exam by pathologist. We find that CPT 
code 88305 is not supported. An independent laboratory may not bill the Medicare contractor (for the technical 
component (TC) of a physician pathology service furnished to a hospital outpatient.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been 
met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on March 28, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehab facility is medical necessary The 
Plan denied your request. The Plan says an intensive rehabilitation program 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 acute IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial imaging, positron emission tomography 
(PET), perfusion study (78430, 78431). 
 
You asked the Plan to pre-approve nuclear stress test. You say that the enrollee had a stress test performed in 
2012. You also say that the enrollee needs this test as soon as possible. The Plan denied your request. The Plan 
says the criteria for coverage 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 nuclear stress test. Our reviewer says 
that the requested nuclear stress test is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation that the echocardiogram (ECG) shows an uninterpretable 
pattern. There is no evidence provided that would support the need for radionuclide stress testing. Therefore, 
the reviewer found there is insufficient documentation to support the medical necessity for the requested 
cardiac stress testing in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nuclear stress test have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a myocardial imaging, positron emission tomography (PET), perfusion study (78430, 
78431).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan has to pay for the cranioplasty services provided on August 9, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
service was billed within the pre-op and/or post-op period. 
 
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. 
 
The file shows that the services were denied as inclusive to a global surgical package. The Plan does not 
provide any other claims, remittance advices, or other documentation to show that this service is included in 
another procedure/service. 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 cranioplasty services provided on August 9, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit with a chiropractor (code 99212) you had on 
July 13, 2022. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you have experienced relief from the 
treatment of this chiropractor, so this should be covered. The Plan denied your request. The Plan says office 
visits are not covered chiropractic services. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit with a chiropractor (code 99212) you had on July 13, 2022.
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 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 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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6539, a 
custom gradient pressure sleeve (S8422) and a mastectomy bra (L8001). 
 
You asked the Plan to pre-approve the compression stockings, gradient pressure sleeve and a mastectomy bra. 
You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The 
Plan says compression stockings are non-covered under the surgical dressing benefit as it does not meet the 
statutory definition of a dressing. There is no clinical to suggest that the enrollee has or had breast cancer or a 
mastectomy, so the mastectomy bra is not covered. The gradient pressure sleeve is a temporary miscellaneous 
supply code and Medicare does not under any circumstances cover s-codes. The s-code in question is not 
payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6539 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Although a gradient sleeve may be appropriate, it does not fall into a covered benefit category 
and cannot be paid for by Medicare or the Plan. The records do not show that the enrollee has or had breast 
cancer or a mastectomy, therefore, the mastectomy bra is not covered. Therefore, we decided that the Plan does 
not have to pre-approve compression stockings identified with code A6539, a custom gradient pressure sleeve 
(S8422) and a mastectomy bra (L8001).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01630) provided on March 29, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 anesthesia services Our reviewer says 
that the records do not support the number of units billed. Our physician reviewer found the anesthesia report 
documents that anesthesia started at 12:52 and ended at 14:00. This time does not support 70 units of the code 
billed. 
 
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 anesthesia services have not been met. Therefore, we decided that the Plan 
does not have to pay for anesthesia services (01630) provided on March 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544-26 billed for date of service May 29, 
2022. 
 
You asked the Plan to pay for procedure code 70544-26. You say that the patient had multiple tests on this date 
of service. The Plan denied your request. The Plan says payment for code 70544-26 is bundled into payment 
for code 70551-26. 
 
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 
70544-26 is a column II code to column I code 70551-26. 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 70544-26 billed for date of service 
May 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on June 22, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for office visit provided on June 22, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite test strips. 
 
You asked the Plan to pre-approve Freestyle Lite test strips. The Plan denied your request. The Plan says this is 
not from a preferred provider. 
 
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 test strips and monitors 
must be obtained from preferred vendors Accu-Chek and OneTouch. Test strips and monitors from any other 
vendor will not be covered.  
 
You have requested coverage of Freestyle Lite test strips. Test strips from this vendor is not covered by the 
Plan. This item falls within the durable medical equipment benefit category. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered. 
 
We looked at the file and Medicare rules. The requested item is a power seat elevation system. This is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services received on March 22, 2022. 
 
You asked the Plan to pay for the injection services. You say that you have no control over the drugs used in 
your treatment. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered for 
certain indications. 
 
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 injection services. Our reviewer says that 
the documentation does not support that the services received were medically reasonable or necessary. Our 
physician reviewer found you have normopressure hydrocephalus and back pain. Your electromyography is 
normal. You are taking Gabapentin 100mg. There is no physical exam documenting radiclopathy or other 
indication for an epidural steroid injection. There is a lack of documentation that supports the need for the 
injection. Therefore, you did not meet criteria for the services received. 
 
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 injection services have not been met. Therefore, we decided that the Plan 
does not have to pay for the injection services received on March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens 
(V2781), and polycarbonate or equal lens (V2784) provided on June 22, 2022. 
 
You asked the Plan to pay for the anti-reflective coating, progressive lens, and polycarbonate or equal lens. 
You say that you believe these lenses should be covered. The Plan denied your request. The Plan says these 
types of upgrades are not covered under your policy. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are standard eyeglass lenses. 
 
We looked at the file and the Plan's rules. The record shows that you received lens upgrades, which are not 
covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the anti-
reflective coating, progressive lens, and polycarbonate or equal lens have not been met. Therefore, we decided 
that the Plan does not have to pay for the anti-reflective coating (V2750), progressive lens (V2781), and 
polycarbonate or equal lens (V2784) provided on June 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth visit (99214) provided on May 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the virtual care. You say that it is your understanding that you should have a $45 
copayment for this service. The Plan denied your request. The Plan says out-of-network virtual care is not 
covered. 
 
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 virtual care performed 
by an out-of-network provider is not covered. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services as the Evidence of 
Coverage clearly states that virtual care performed by an out-of-network provider is not covered. Therefore, we 
decided that the Plan does not have to pay for the telehealth visit (99214) provided on May 16, 2022, by an out-
of-network (OON) provider.