Persius/hicric huggingface dataset:
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 you need the rehabilitation admission because you 
fall and need to get stronger. The Plan denied your request. The Plan says admission to IRF was denied as not 
meeting criteria, is not medically necessary, and a lower level of care might be appropriate. Your needs can be 
met in a skilled nursing facility 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 you are modified independent and using a wheelchair for mobility. You require 
contact guard assistance for transfers and moderate to maximum assistance for dressing. You had a functional 
decline from your baseline level of function and require assistance. You would likely benefit from therapy, but 
you do not require the intensity of therapies provided on acute inpatient rehabilitation. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the clinical information provided supports the need 
for SNF care. The Plan denied your request. The Plan says the records do not show that the enrollee needs 
nursing care that is not provided by hospice. The Plan says that the records do not show that the enrollee needs 
daily therapy or other daily services that can only be given at a SNF. The Plan says that, based on the enrollee's 
current needs, care can be provided by hospice.  
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 the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition.  The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided at 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 77012 billed for date of service April 13, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says that an appropriate modifier was not 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 denied procedure code 77012 as payment is bundled into payment for code 49083. However, the 
documentation in the case file does not show that procedure code 49083 was billed for this enrollee on the date 
of service at issue. 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 
procedure code 77012 billed for date of service April 13, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on December 20, 
2021.  
You asked the Plan to pay for the at-home COVID-19 test kits. You say that you spoke with a Plan 
representative who advised you were eligible for reimbursement for these test kits. The Plan denied your 
request. The Plan says neither Medicare nor the Plan covered at-home COVID-19 test kits in 2021. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 test kits are an OTC item. The contract clearly states that coverage for these tests through the Plan 
began on February 1, 2022. These tests were purchased before February 1, 2022, and are not covered. The 
Plan's call log with you also states you were advised that the tests are not eligible for reimbursement. 
Therefore, we decided that the Plan does not have to pay for the at-home COVID-19 test kits purchased on 
December 20, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing (G0481, 80307) provided on May 10, 2022. 
 
You asked the Plan to pay for drug testing. You say that these services were reported correctly and are 
supported in the medical record. The Plan denied your request. The Plan says that this service is not supported 
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, the CPT Code Manual definition of 
code G0481 is drug test(s), definitive, utilizing one drug identification method able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including specimen validity 
testing, 8-14 drug classes. 
 
We find that CPT code G0481 is supported in the medical record. Specifically, the records indicate that drugs 
from between 8-14 classes have been tested in this case, including amphetamines, buprenorphine, fentanyls, 
methadone, opiates, opioids and opiate analogs, oxycodone, propoxyphene, tapentadol and tramadol classes. 
Based on this information, we decided that Medicare rules for coverage of drug testing have been met. 
Therefore, we decided that the Plan has to pay for drug testing (G0481, 80307) provided on May 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62321). 
 
You asked the Plan to pre-approve the injection. You say that the enrollee's imaging from January 2022 
indicates straightening of the cervical lordosis. You also say that this could have resulted in disc degeneration, 
which was not yet evident on the imaging from January 2022. The Plan denied your request. The Plan says the 
requested injection is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements 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 the injection. Our reviewer says that the 
requested epidural steroid injection (ESI) is not medically necessary. Our physician reviewer found the 
provided imaging does not support that the enrollee has lumbar, cervical or thoracic radiculopathy, radicular 
pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe 
degenerative disc disease, producing foraminal or central spinal stenosis. Therefore, the reviewer found that the 
requested ESI is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection (62321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this device is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 
considered 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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of implant (D6010) provided on May 
19, 2022. 
 
You asked the Plan to pay for a surgical placement of implant. You say that you want the Plan to pay for the 
service. The Plan denied your request. The Plan says criteria are not met for coverage of this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
 
 
 
 
 
 
 
 We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a surgical placement of implant have not been met. Therefore, we decided that the Plan does not 
have to pay for a surgical placement of implant (D6010) provided on May 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with a sit-to-stand feature, shock-
reducing pylon, advanced foot, and other parts. 
 
You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria of being reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the items. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no evidence of comorbidity of the spine and/or sound limb affecting hip extension and/or 
quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a prosthetic leg with a sit-to-stand feature, shock-reducing pylon, advanced foot, and other parts.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance services provided on January 4, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that you have provided medical 
records to support payment. The Plan denied your request. The Plan says you did not have authorization to 
provide this non-emergency service. 
 
Medicare rules say that plans can require prior authorization. The contract with the Plan says that the Plan 
requires prior authorization for non-emergency ambulance services. In this case, you did not request prior 
authorization for the non-emergency ambulance services and 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 non-emergency ambulance services provided on January 4, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry office visit provided on May 24, 
2022. 
 
You asked the Plan to waive the copayment for podiatry office visit. You say that previous claims did not have 
a copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 you must pay a $40 
copayment for podiatry services. 
 
You have been asked to pay a $40 copayment for podiatry office visit. This item/service falls within the 
podiatry services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan.   
 
 
  
Therefore, we decided that the Plan does not have to waive the copayment for podiatry office visit provided on 
May 24, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for PET scan provided on April 13, 2022. 
 
You asked the Plan to reduce the copayment for PET scan. You say that the evidence of coverage is confusing. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 you must pay a $250 
copayment for outpatient diagnostic tests and therapeutic services. 
 
You have been asked to pay a $250 copayment for PET scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan.  
 
 
 
  
 Therefore, we decided that the Plan does not have to reduce the copayment for PET scan provided on April 13, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the synvisc injection provided on May 16, 
2022. 
 
You asked the Plan to waive the coinsurance for the synvisc injection. You say that the provider did not tell 
you about the bill for the injection. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for the synvisc injection. This item/service falls within the 
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. You have been asked to pay $99.42, which is 20% of the allowed amount for 
the injection ($497.11 allowed amount x 20% coinsurance = $99.42). Therefore, we decided that the Plan does 
not have to waive the coinsurance for the synvisc injection provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99203 billed for date of service September 8, 
2021. 
 
You asked the Plan to pay for procedure code 99203. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says procedure code 99203 is considered bundled and not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99203 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99203 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99203 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99203 billed for date of service September 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for office visits on February 17, 2022, and March 3, 
2022. 
 
You asked the Plan to waive the copayment for office visits. You say that you should not be responsible to pay 
this. The Plan denied your request. The Plan says that the cost share was applied correctly. 
 
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 has not forwarded an Explanation of Benefits. The 
documentation submitted does not include any evidence of what was billed or what cost share amount was 
applied. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has 
not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the 
copayment for office visits on February 17, 2022, and March 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient dialysis treatments provided 
January 1, 2022, to March 31, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient dialysis treatments. You say that the enrollee cannot 
afford to pay this. The Plan denied your request. The Plan says the cost share has been applied correctly. 
 
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 you must pay a 20% 
coinsurance for outpatient dialysis treatments.  
 
You have been asked to pay $2566.80 for outpatient dialysis treatments. Outpatient dialysis treatments fall 
within the Services to Treat Kidney Disease benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for outpatient dialysis treatments provided January 1, 2022, to March 31, 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 home health will not give you the care needed to get 
well. The Plan denied your request. The Plan says the services needed can be provided in another 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 physician reviewer found 
that you were failing treatment with peritoneal dialysis. You were admitted to the hospital with a plan to 
remove the peritoneal dialysis catheter and to place a hemodialysis catheter. You tolerated hemodialysis well.  
 You tolerated standing for 5-7 minutes. You were ambulating 10 feet with a rolling walker and gait belt, with 
minimal contact assistance. It is not clear that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. While you require treatment by multiple therapies, 
it is not clear that you require at least 3 hours a day. The complexity of your nursing, medical and rehabilitation 
needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.