Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care procedures provided on 
February 02, 2022, to March 02, 2022. 
 
You asked the Plan to waive the copayment for wound care procedures. You say that you had already met your 
$3000 maximum out of pocket (MOOP) amount and should not owe aniything else. 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 $25 
copayment for podiatry services. 
 
You have been asked to pay a $25 copayment for wound care procedures. 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. You had three visits, each with a $25 copayment, bringing the total copayment amount to $75 ($25 
x 3 = $75). Therefore, we decided that the Plan does not have to waive the copayment for wound care 
procedures provided on February 02, 2022, to March 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and a mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee had a stroke and lost her 
dentures while at rehab. The Plan denied your request. The Plan says the enrollees benefit for the requested 
item or service has already been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the benefit for the mandibular partial denture (D5226) was exhausted on date of service September 29, 
2020, and the benefit for the maxillary partial denture (D5225) was exhausted on date of service November 2, 
2021. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5225) and 
a mandibular partial denture (D5226).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81599) provided on November 1, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The plan confirmed by telephone outreach that the provider listed on 
the claim did not order the genetic testing billed. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
genetic testing (81599) provided on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have irritable bowel syndrome 
(IBS) and your incontinent. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided on June 2, 2022 to June 7, 
2022. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you have the right to file this appeal. You 
say that you would like the inpatient hospital stay be covered by the Plan. The Plan denied your request. The 
Plan says our records show you were medically stable for transfer to an in-network provider for treatment but 
refused. You do not have out-of-network benefits. There are providers in your network within a reasonable 
distance who could treat your diagnosis and had accepted your transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 an inpatient hospital stay. Our reviewer says 
that the treating physician did not document that you were not stable for transfer on any dates of service. Our 
physician reviewer found you presented to the hospital with chest pain, productive cough, chills with imaging 
showing pneumonia. You were stable to transfer by ambulance to an in-network hospital on June 2, 2022 as 
you denied shortness of breath, had stable vitals except for tachycardia, was tolerating oral, and initial workup 
ruled out acute coronary syndrome, and pneumonia based on the provided documentation. Records describe 
you refused transfer to an in-network facility when offered. 
 
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 inpatient hospital stay have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital stay provided on June 2, 2022 to June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99235) provided on June 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not 
payable. 
 
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 99235 is "Observation or inpatient hospital care, for the 
evaluation and management of a patient including admission and discharge on the same date, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. 
Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We find that CPT code 99235 is not supported in the medical record. Specifically, the records do not show that 
the enrollee was admitted and discharged on the same date. 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 services (99235) provided on June 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for DME provided on March 16, 2022. 
 
You asked the Plan to reduce the coinsurance for DME. You say that your provider informed you of the 20% 
cost-share, which you feel is too much and unable to afford. You say that you would like the plan to match the 
retail price you located online. 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-covered durable medical equipment and related supplies.  
 
You have been asked to pay a coinsurance of $647.06, which is 20% of the allowed amount for DME 
($3,235.30 allowed x 20% = $647.06). This item/service falls within the Durable Medical Equipment (DME) 
and Related Supplies 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 coinsurance for DME 
provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that if the enrollee were to go home, they would be at fall 
risk. You also say that the enrollee is weak and unable to walk on his own and limited to his functional status. 
The Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements 
for approval. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
can receive further services 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you researched and found one in-network 
provider, however you say you need to see the out-of-network provider because you can get an earlier 
appointment. The Plan denied your request. The Plan says the service can be provided by an in-network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan has found multiple in-network 
providers in your area. We found no exception that would require the Plan to pre-approve these items/services. 
Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-
network (OON) provider.
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 you are unable to walk due to surgery and will 
require after-surgery care. You say you need medical care, occupational therapy and physical therapy in order 
to regain a sense of independence. The Plan denied your request. The Plan says the IRF is not medically 
necessary, and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 medically stable and does not need a physician's supervision three times a 
week in an IRF. There are no acute rehabilitation nursing needs identified or documented. You do not need 
intensive therapies consisting of at least three hours of therapy per day at least five days per week with 
multidisciplinary approach in an IRF. You will not tolerate IRF level of intensity with therapies and make a 
significant functional recovery in a reasonable period in an acute rehabilitation 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care. 
The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The 
enrollee's medical needs are being met in the current acute setting. 
 
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 setting. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (95907, 95886, 95937) provided on March 30, 
2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
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. 
 
We asked our coder 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 use of codes 95907, 
95886, and 95937, is not supported by the records provided. Our reviewer found that for CPT 95907, the 
procedure report does not describe NCCI Policy criteria for nerve conduction studies. The procedure report 
documents ""Sensory Nerve Action Potential (SNAP) demonstrated adequate stimulation to produce". In this 
case, nerve conduction studies cannot be verified. For CPT 95886, nerve conduction studies cannot be verified, 
therefore this procedure would not be covered. For CPT 95937, the procedure report describes train of four testing, and would not be reported with the neuromuscular junction testing procedure code. Procedure report 
documents: "Results: TO4 was utilized throughout the procedure in order to assess level of paralysis due to 
administration of relaxant by anesthesia". There is no procedure code for TO4 testing, as it is included in the 
neuromonitoring procedure code. 
 
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 the services (95907, 95886, 95937) provided on March 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the power wheelchair will improve the 
enrollee's mobility. The Plan denied your request. The Plan says there are in-network providers who can 
provide this service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve durable 
medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis, 51 or greater 
genes, Myeloid disorder panel (81455). 
 
You asked the Plan to pre-approve Myeloid disorder panel. You say that the request for myeloid disorder panel 
was denied. You are submitting appeal with clinicals attached. The Plan denied your request. The Plan says this 
request is not medically necessary because this test is not on the list of FDA approved companion in vitro 
diagnostic devices. 
 
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 Myeloid disorder panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee has thrombocytosis. The record sent by the provider 
indicates the enrollee had a blood smear in June 2022 concerning for essential thrombocythemia versus 
idiopathic myelofibrosis. The provider ordered a Neotype Myeloid Disorder Profile by Next Generation 
Sequencing. Under Medicare guidelines, the request is not medically necessary because this test is not on the 
list of FDA approved companion in vitro diagnostic devices. The review has determined that the records do not 
support that the enrollee meets the medical necessary criteria for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myeloid disorder panel have not been met. Therefore, we decided that the Plan 
does not have to pre-approve targeted genomic sequence analysis, 51 or greater genes, Myeloid disorder panel 
(81455).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay, and the ER visit 
provided from September 26, 2020, to September 30, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital stay and the ER visit. You say that this 
should be covered. 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 $90 
copayment per visit to the ER and $310 copayment per day for 1 through 7 of inpatient hospital stay.  
 
 
 You have been asked to pay a total of $1,330 copayment for inpatient hospital stay and the ER visit. This 
item/service falls within the Emergency care and Inpatient hospital stay 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 inpatient hospital stay, and the ER visit provided from September 26, 
2020, to September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. 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 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimens were collected on March 2, 2022, and March 3, 2022. This means there is no documentation 
to support the billed date of service of April 1, 2022. Based on this information, we decided that Medicare rules 
for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on April 1, 2022.