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 April 4, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the wrong date of service. 
 
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 payment for CPT code 81455 is not supported in the medical record. Specifically, the claim must 
be billed with the date the specimen was collected. The records show that the specimen was collected on 
January 4, 2022, and February 24, 2022. As such, the claim was billed with the incorrect date of service. 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 April 4, 2022.
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 IRF care is the patient's only chance at returning to 
her previous level of function. The Plan denied your request. The Plan says the patient does not require an IRF 
level of care and can be managed in a lower setting. 
 
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 patient is medically stable and does not need a physician's supervision 3 times a week in an IRF. No acute rehab nursing needs are identified or documented in the medical record. At the 
current functional level (minimal assist for mobility with inability to follow complex commands), the patient 
does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach in an IRF. The documentation does not support necessity for admission to an IRF 
with no medical complexity or nursing needs and high functional mobility. While the patient may benefit from 
continued therapy, the patient's rehab needs can be safely provided in a lower intensity and alternate 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 that you are frail with a major underlying chronic illness. Intensive rehabilitation is 
not reasonable or necessary. You have chronic rehabilitation needs and cannot fully participate in intensive 
rehabilitation. You do not have any medical issues precluding routine rehabilitation services or which require 
an inpatient stay. Your functional status does not require intensive, complex or specialized rehabilitation in 
order to regain function. You do not require frequent physiatry oversight or rehabilitation nursing. 
 
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 pay for the outpatient clinic visit provided on March 30, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient clinic visit. You say that you were unaware that prior authorization 
was required for the services that were rendered to the enrollee. The Plan denied your request. The Plan says 
the rendering provider is an OON provider and there was no approved authorization. Also, the service rendered 
was not urgent or emergent. 
 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 the outpatient clinic visit provided on March 30, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on July 12, 2022. 
 
You asked the Plan to pay for the eye refraction. You say that you would like this service to be covered. The 
Plan denied your request. The Plan says refractive services are not covered under your medical benefit plan. 
The Plan also says that eye refractions are only covered when they are performed during a routine screening. 
 
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 eye refractions performed during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that this eye refraction was performed with a 
medical diagnosis of other secondary cataract, right eye. Based on this information, we decided that the Plan's 
rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to 
pay for the eye refraction provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs 
transportation to medical appointments. The Plan denied your request. The Plan says the enrollee has utilized 
the maximum number of transportation trips allowed per year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed for date of service April 6, 2022. 
 
You asked the Plan to pay for lab services. You say that the test was ordered to determine the best course of 
treatment for the specific cancer and clinical presentation. You say that the test was medically necessary. The 
Plan denied your request. The Plan says the date of service for a clinical laboratory test or the technical 
component of physician pathology service must be the date the specimen was collected. 
 
  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 81455 is not supported in the medical record. Specifically, an incorrect date of service 
was billed. Based on this information, we decided that Medicare rules for coverage of lab services have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services billed for date of service 
April 6, 2022.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that 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 found to be medically reasonable and necessary. Our physician reviewer found that the 
documentation shows that you have many active comorbidities and hospital complications and would require 
close medical supervision on an inpatient basis during rehabilitation. Evaluating therapists recommend intense 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested drug. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Aranesp. Our physician reviewer found the Plan requires a 
trial of Retacrit or Procrit (Epoetin Alfa) before they will approve the requested drug. In this case, the enrollee 
has not tried and failed the required drugs. Our reviewer also found that there is no documentation provided 
indicating that the Plans required drugs would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the documentation shows that the enrollee has multiple active comorbidities and hospital complications 
and would require close medical monitoring on an inpatient basis during rehabilitation. Evaluating therapists all 
recommend intense therapy thus IRF criteria have been met and IRF 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS). 
 
You asked the Plan to pre-approve rTMS. You say that rTMS is medically necessary. The Plan denied your 
request. The Plan says medical necessity criteria have not been met, as major depressive disorder, moderate, 
recurrent is not a covered diagnosis. 
 
The Plan follows Medicare rules.  
 
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 rTMS. Our reviewer says that rTMS is 
not medically necessary. Our physician reviewer found based on the information provided, this enrollee does 
not meet the clinical criteria for the use of Transcranial Magnetic Stimulation therapy as he is diagnosed Major 
Depressive Disorder Recurrent Moderate which is not considered a disease that meets the criteria for the use of 
Transcranial Magnetic Stimulation. There is no documentation of the enrollee undergoing psychotherapy and 
there is no list of medications which this enrollee had been tried on other than his present medications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of rTMS have not been met. Therefore, we decided that the Plan does not have to 
pre-approve rTMS).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 24, 2022, billed with 
codes 81404, 81405, 81406 and 81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
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 
January 24, 2022, billed with codes 81404, 81405, 81406 and 81407.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of the current prosthesis (socket, advanced 
knee, and advanced foot). 
 
You asked the Plan to pre-approve the prosthetic replacement. You say that it is felt that this replacement is 
medically necessary. The Plan denied your request. The Plan says based on the information provided, a 
replacement socket could be approved if requested. However, the replacement of the entire limb is not 
reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for the replacement of a 
prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines 
that the replacement device or part is necessary due to one of the conditions listed 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 the prosthetic replacement. Our reviewer says that the requested items do not meet the criteria for prosthetic limb replacement. Our physician 
reviewer found the patient was approved for a level 3 knee and foot on March 31, 2022, which is under a 36-
month warranty. The documentation indicates that the patient wants to replace his microprocessor knee with a 
mechanical knee due to the heavy weight of the microprocessor knee. The documentation does not meet 
medically necessary criteria as the reason for replacement is not due to a change in the physiological condition 
of the patient; an irreparable change in the condition of the device, or that the device needs repairs.  
 
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 prosthetic replacement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve replacement of the current prosthesis (socket, advanced knee, and advanced 
foot).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee would benefit from skilled nursing 
services due to their medical complexity. The Plan denied your request. The Plan says the enrollee's needs can 
be met in a hospital setting or at home with supervision and home health services. The enrollee's needs may 
also be met from part-time skilled services in long-term care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 a prescription from the podiatrist for an orthotic 
for your foot should be covered. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary function testing rendered on February 18, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 94727 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 94727 is gas dilution or washout for determination of 
lung volumes and, when performed, distribution of ventilation and closing volumes. 
 
We find that CPT code 94727 is not supported in the medical record. Specifically, there is no documentation of 
results for gas dilution or washout for determination of lung volumes. 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 pulmonary function testing rendered on February 18, 2022.