Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hip orthosis provided on January 11, 2022. 
 
You asked the Plan to pay for the orthosis. You say that the billed claim is payable. The Plan denied your 
request. The Plan says there is no information that the brace was ordered or required by the physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the medical documentation. 
 
We looked at the file and the rules. The medical records provided did not contain sufficient documentation of a 
medical condition to substantiate the orthosis. There is no documentation of concern, prognosis, or treatment 
strategy for a hip condition. Based on this information, we decided that Medicare rules for coverage of the 
orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the hip orthosis 
provided on January 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve insertion of an ILR. 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 insertion of an ILR. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the ILR had been placed for syncope and atrial fibrillation, which have not been 
observed for years. As such, based on current guidelines and the documentation provided, there is insufficient 
clinical evidence to support the medical appropriateness and necessity of replacing the enrollee's old ILR with a 
new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Minuteman procedure. 
 
You asked the Plan to pre-approve Minuteman procedure. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because Minuteman is experimental/investigational. 
 
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 Minuteman procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental procedure with an ongoing trial. There is no long-term follow-
up data. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Minuteman procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Minuteman procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for eyeglasses you purchased on December 14, 2021.  
You asked the Plan to pay more for the eyeglasses. You say that you have never submitted a claim for 
eyeglasses before, so you don't know how you could have exhausted your benefit. The Plan denied your 
request. The Plan says it has already applied $150 towards this eyeglass purchase.  The total cost of the 
eyeglasses was $249.98. The remaining $99.98 after the $150 allowance is your responsibility. 
 
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 eyewear only up to the $150 allowance.  The Plan has already applied this allowance 
to the claim for these eyeglasses.  Because the cost of the eyeglasses was more than $150, you are responsible 
for the difference. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
additional payment for the eyeglasses have not been met. Therefore, we decided that the Plan does not have to 
pay more for eyeglasses you purchased on December 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
December 30, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed.  
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 the Computed tomography (CT) scan (70450) provided on 
December 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant to surgery services provided on October 4, 
2021. 
 
You asked the Plan to pay for the assistant to surgery services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant to surgery services 
provided on October 4, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the anesthesia services (01830-QK-QS-P3) provided on September 3, 
2021. 
 
You asked the Plan to pay for code 01830-QK-QS-P3. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that this claim is a duplicate of another claim 
that was paid. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole denial rationale in this case is that the claim in 
question for procedure code 01830-QK-QS-P3 is a duplicate of another claim. However, the only other claim 
submitted in this file by the Plan is not a duplicate. The other claim provided by the Plan is for the same date of 
service, but for a completely different code. The other claim is for 30 minutes of procedure code 00811-QK-
QS-P2 related to only one diagnosis (R194). The claim in question in this appeal is for 114 minutes of code 
01830-QK-QS-P3, related to three separate (and different) diagnosis codes: M869, I120, N186, and F17200. 
Because these were the only two claims submitted by the Plan in their case submission to us, we can only 
assume that these are the two claims that the Plan is calling 'duplicates.' As noted above, these claims are not 
duplicates of one another. The Plan has provided no other basis to support its denial. Therefore, we decided that 
the Plan has to pay for the anesthesia services (01830-QK-QS-P3) provided on September 3, 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: 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 SNF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for SNF care and the services she 
requires are called custodial care, which helps the enrollee with daily needs such as dressing, bathing, getting in 
and out of bed, going to the bathroom, and eating. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care
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 LTACH services. You say that LTACH services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee is receiving appropriate inpatient care at the 
current hospital and can remain there until ready for discharge to a lower level of care. 
 
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 that all medically necessary care is being provided in the current acute care 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural lumbar injection. 
 
You asked the Plan to pre-approve an epidural lumbar injection. 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 follows Medicare rules. Medicare rules say that epidural steroid injections are covered when specific 
criteria are met. 
 
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 epidural lumbar injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, there has 
not been a second confirmatory set of diagnostic medial branch blocks (MBBs). The review has determined 
that the enrollee does not meet the coverage criteria detailed in the LCD. 
 
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 epidural lumbar injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural lumbar injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Magnetic resonance (eg, proton) imaging (MRI) (72141, 
72148), provided on September 22, 2021. 
 
You asked the Plan to pay for the MRI. You say that the service should be covered. The Plan denied your 
request. The Plan says no documentation was submitted indicating that two separate services were performed. 
 
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 Magnetic resonance (eg, proton) 
imaging (MRI) (72141, 72148), provided on September 22, 2021. have been met. Specifically, no 
documentation was submitted indicating that two separate services were performed. Therefore, we decided that 
the Plan does not have to pay for the Magnetic resonance (eg, proton) imaging (MRI) (72141, 72148), provided 
on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided to the enrollee on October 1, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the required information was not received. 
 
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 wound care services provided to the 
enrollee on October 1, 2021 have been met. Despite multiple requests and attempts from the plan, the provider 
has not sent in any medical records for this claim. Therefore, we decided that the Plan does not have to pay for 
wound care services provided to the enrollee on October 1, 2021.
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 LTACH services. You say that the enrollee currently meets LTACH 
admission criteria and his ongoing medical needs warrant an LTACH level of care to achieve a safe and 
sustainable discharge. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can safely receive his dialysis and PT/OT in an alternate setting such 
as a skilled nursing facility or at home with home health services. 
 
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 that the medical records do not indicate that the enrollee requires services that he is 
not currently receiving at the current hospital. 
 
 
  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: 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 enrollee is an appropriate candidate for IRF. The 
Plan denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee has a need for physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in 
- and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on October 24, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you were treated in your hotel room while 
you were in New York. You say that you were not transported. You also say that you would like this claim to 
be paid. The Plan denied your request. The Plan says since no transport was provided, there is no payable 
service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 24, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on October 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on September 28, 2021. 
You asked the Plan to pay for the testing services. You say that the system connects physicians with treatment 
options. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 
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 looked at the file and the rules. The gene panel was billed with multiple codes. The medical records 
provided do not show that the service billed with the -59 modifier is a distinct procedural service. If a single 
procedure is performed, only one code with one unit of service may be reported for the procedure. Based on 
this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the gene panel provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel provided on June 21, 2021. 
 
You asked the Plan to pay for the testing services. You say that the panel reports relevant somatic alterations. 
The Plan denied your request. The Plan says one code must be submitted for the panel. 
 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 the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. 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 gene panel provided on June 21, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the genetic testing services provided on October 6, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the testing 
is unlikely to impact therapeutic decision-making. 
 
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 file shows that the Plan denied genetic testing submitted with code 
81455. However, the claim information shows that code 81445 is at issue. The Local Coverage Determination 
and Article the Plan used in their decision to deny services does not indicate that code 81445 is automatically 
denied as not medically necessary due to being unlikely to impact therapeutic decision-making in the clinical 
management of the enrollee. 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 genetic testing services provided on October 6, 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.