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

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee is medically unstable with leukocytosis and hypotension requiring 
pressor support. The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH 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: 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 medically necessary. The Plan 
denied your request. The Plan says IRF 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 the enrollee does not require intensive or complex rehabilitation. She does not require 
frequent physiatry oversight. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Deuk Laser Disc Repair, left approach at L4-5 provided 
to the enrollee on September 30, 2021. 
 
You asked the Plan to pre-approve the services. You say that this surgery was of urgent and emergent nature. 
The Plan denied your request. The Plan says there is not enough medical evidence about this type of procedure. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that laser disc repair is experimental. More research is needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Deuk Laser Disc Repair, left approach at L4-5 provided to the enrollee on September 30, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there appears to be some concern that the devices are not as effective as surgical 
decompression and could lead to higher rates of reoperation. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex Superion interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that an authorization is not required for the service that 
was provided to the enrollee. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. 
  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 an office visit provided on March 15, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that you enable physicians to deliver personalized 
cancer care. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. 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. The claim was billed 
with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
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 lab services provided on November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye refraction (92015) provided on December 7, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that prior to this appointment, you contacted the Plan 
and requested in-network providers. You also say that you feel the insurance should pay the remaining $47.00 
because you did your best to find an in-network provider. The Plan denied your request. The Plan says that 
your maximum benefit has been exceeded. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The record shows that you contacted the Plan on December 3, 2021. During this call, you were advised by a 
Plan representative that the facility you were treated at was in-network with the Plan. The Plan did not indicate 
during this call that there were any out-of-network providers at this office. The file does not show that the Plan 
provided notice that the eye refraction would not be covered. Under Medicare rules, this means the eye 
refraction is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the eye 
refraction (92015) provided on December 7, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 31, 2021. 
 
You asked the Plan to pay for the laboratory 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on December 31, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for an advanced level (K3) prosthetic foot. 
 
You asked the Plan to pay for the requested foot. The Plan denied your request. The Plan says that the records 
do not support that the enrollee is a K3 ambulator. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain 
medical indications.  
 
The records show that a shank foot system with vertical loading pylon (L5987) was requested. 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 requested foot. Our physician reviewer found that you 
have a past medical history of left ankle fracture with complications leading to a left below-knee amputation. 
Clinical documentation shows that you would be expected to traverse different terrains with different cadencies 
at a K3 level. Therefore, the requested foot (L5987) is medically reasonable and 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 the requested foot have been met. Therefore, we decided that the Plan has to 
pay for an advanced level (K3) prosthetic foot.  
 
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 anesthesia services provided to the enrollee on January 5, 
2022. 
 
You asked the Plan to pay for the services. You say that the records should be reviewed to reprocess this claim 
for payment. The Plan denied your request. The Plan says this procedure is not paid separately. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. 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 anesthesia 
services provided to the enrollee on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an esophageal function test provided to the enrollee on 
August 5, 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 there is no clinical information submitted to support the medical necessity of the esophageal 
function test, or that the test was performed. 
 
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 91037 is "Esophageal function test, gastroesophageal 
reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and 
interpretation." 
 
We asked our 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 services. Our reviewer says that the services at issue 
in this case were not supported by the medical records. Our reviewer found that while esophageal manometry is 
commonly performed to assess swallowing and esophageal sphincter function, its indication in the enrollee's 
case was not specified nor was the test completed. The available records do not warrant coverage of the service 
as either medically necessary not appropriate. 
 
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 an esophageal function test provided to the enrollee on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on December 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at home COVID-19 test kits purchased January 21, 2022. 
 
You asked the Plan to pay for the test kits. You say that the test kits were medically necessary and should be 
covered. The Plan denied your request. The Plan says the test kits were not a covered item at the time they were 
purchased. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. In this case, plan rules apply. 
The plan covers up to 8 FDA-approved COVID-19 test kits, effective February 1, 2022.  
 
We looked at the file and Medicare rules. The test kits were purchased on January 21, 2022, prior to the 
effective date of this benefit. Based on this information, we decided that Medicare rules for coverage of the test 
kits have not been met. Therefore, we decided that the Plan does not have to pay for at home COVID-19 test 
kits purchased January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 6, 2021. 
 
You asked the Plan to pay for the laboratory 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 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 denied CPT code is not supported in the medical record. Specifically, the testing at issue in 
this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on April 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care services provided to the enrollee from 
September 7, 2021, to September 16, 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 provider did not follow Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The RAP for these services was not submitted in a timely manner in this case.  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 home health care services provided to the enrollee from September 7, 2021, to 
September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on December 29, 2021. 
 
You asked the Plan to pay for code 0037U. 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. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. The gene panel provided includes the FANCC gene. In addition to 
single gene testing, MolDX will also deny panels of tests that include the FANCC gene. Based on this 
information, we decided that Medicare rules for coverage of code 0037U have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing (0037U) provided on December 29, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to reimburse you for the Oral device/appliance (E0486) provided on November 1, 
2021. 
 
You asked the Plan to reimburse you for the Oral device/appliance. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says that they were unable to provide you with 
a determination in the allotted time frame. 
 
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. The Plan has provided no rationale for why the claim was initially denied. There 
is no evidence provided by the Plan to support the denial of payment per Medicare guidelines. Therefore, we 
decided that the Plan has to reimburse you for the Oral device/appliance (E0486) provided on November 1, 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory service (81238) provided on May 20, 2021. 
 
You asked the Plan to pay for code 81238. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan denied payment for code 81238 because the laboratory 
billed multiple codes on multiple claims with the same date of service when the procedures should have been 
report with the most comprehensive code that describes the services performed. However, the Plan provided no 
other claims for review to support this. The Plan says that the laboratory shall report only one unit of service of 
one procedure code. The file shows the provider billed one unit of 81238. The Plan has provided no other 
rationale for their denial of payment. We find that the Plan has not supported their reason to deny payment for 
these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for the laboratory 
service (81238) provided on May 20, 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.