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

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(Tdap) (90715) provided on September 8, 2021. 
 
You asked the Plan to pay for the vaccine. You say that this vaccination was necessary for your health. The 
Plan denied your request. The Plan says the diagnosis code for this visit is not considered an appropriate 
diagnosis for a Tdap vaccine. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715) provided on September 8, 2021.  
 
Benefits for the vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 are requesting reconsideration of the denied 
authorization for acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on 
Medicare guidelines, the inpatient rehabilitation facility 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 enrollee currently resides in an assisted living facility. The enrollee has not 
had a recent significant change in baseline medical conditions or neurological status and does not require the 
intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. There are no 
complex nursing or rehabilitation needs. While the enrollee has a need for physical or occupational therapy, 
there is no documentation of a need for an intensive rehabilitation program. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
January 4, 2022, to January 25, 2022. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you were unaware of 
these copayments, and they will cause a hardship. The Plan denied your request. The Plan says the copayments 
applied were correct. 
 
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 outpatient rehabilitation services. You had three visits, resulting in a $120 total copayment ($40 
x 3 = $120). 
 
You have been asked to pay a $120 copayment for physical therapy visits. Physical therapy visits fall within 
the Outpatient Rehabilitation 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 copayments for 
physical therapy visits provided from January 4, 2022, to January 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 14, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service May 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 24-trip limit. 
 
You asked the Plan to pre-approve additional trips for routine transportation. You say that it is necessary for the 
enrollee to have transportation to follow-up appointments. The Plan denied your request. The Plan says the 
enrollee has exhausted 2022 routine transportation benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. The Plan provide documentation showing 
that 24 routine transports have been covered. Based on this information, we decided that you have exhausted 
the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not 
have to pre-approve additional trips for routine transportation beyond the Plan's 24-trip limit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 29, 
2022, to February 25, 2022. 
 
You asked the Plan to pay for procedure code S9328. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the billed code is invalid for Medicare 
purposes. 
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 29, 2022, to February 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic shoes and inserts to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you were unaware that you 
would need to obtain authorization for diabetic shoes and inserts. The Plan denied your request. The Plan says 
the provider is out-of-network. 
 
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 diabetic shoes and inserts. We found no exception that would require the Plan to 
pre-approve the diabetic shoes and inserts. The records provided for review do not show that the services at 
issue were urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the diabetic shoes and inserts to be provided 
by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this ventilator is medically necessary for 
your condition. The Plan denied your request. The Plan says the denial of authorization for this device is 
correct, because Medicare does not cover ventilators used in this way and your needs could be met by a bilevel 
positive airway pressure (BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for the enrollee 
to receive LTACH services. The Plan denied your request. The Plan says there are no required medical services 
in the long-term acute care hospital that the enrollee is not already receiving in their current approved hospital 
setting. As acute care hospitals and long-term acute care hospital are licensed to provide the same level of care, 
there is no advantage in moving the enrollee from the current acute care hospital to a long-term acute care 
hospital. 
 
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 enrollee appears to be more stable but still requires short-term additional 
acute care services such as additional weaning and treatment of findings on chest x-rays that can safely be 
administered at the current facility until more stable and appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility. There are no services at 
the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer 
to the LTACH is not medically necessary at this time as it would not be clinically advantageous. Completion of 
treatment at the current facility is recommended. 
 
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an arthrocentesis performed on  
February 15, 2022. 
 
You asked the Plan to waive the coinsurance for an arthrocentesis. You say that you should not be responsible 
to pay this coinsurance. The Plan denied your request. The Plan says the coinsurance 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 Medicare-covered outpatient hospital services.  
 
You have been asked to pay $28.88 for an arthrocentesis. An arthrocentesis falls within the Outpatient Hospital 
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 coinsurance for an arthrocentesis 
performed on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to hold the enrollee harmless for inpatient rehabilitation facility (IRF) care 
provided from March 1, 2021, to March 31, 2021. 
 
You asked the Plan to hold the enrollee harmless for IRF care. You say that you feel that this was medically 
necessary. The Plan denied your request. The Plan says that this IRF care was not medically necessary. 
 
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. 
 
This IRF care was provided by an in-network hospital. The file does not show that the plan provided notice that 
IRF care would not be covered. Under Medicare rules, this means IRF care is considered approved by the plan. 
Therefore, we decided that the Plan has to hold the enrollee harmless for inpatient rehabilitation facility (IRF) 
care provided from March 1, 2021, to March 31, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that corneal disease and have been treated for 13 
years by the requested OON provider. You also say this doctor monitors your condition every 3 months at most 
and prescribed a medication that also needs to be monitored closely due to side effects. The Plan denied your 
request. The Plan says this service is not an emergency, and is able to be rendered in-network. 
 
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. 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 
an office visit to be rendered by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional mileage. You say that you have upcoming appointments and need 
transportation. The Plan denied your request. The Plan says it was verified that the shortest route is 73 miles. 
The Plan also says that this request is not covered by the health plan, it will exceed your benefit mileage limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that you would benefit from this so you do not have to 
worry about the stress of testing your blood sugar. The Plan denied your request. The Plan says you do not 
meet the Medicare criteria for a continuous glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with your 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty walker with seat attachment. 
 
You asked the Plan to pre-approve a heavy-duty walker with seat attachment. You say that this equipment is 
medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker (E0148, E0149) is covered 
for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that you do not weigh more 
than 300 pounds as required by Medicare coverage rules for the heavy-duty walker. As the heavy-duty walker 
cannot be covered, the related seat attachment is also not covered. Based on this information, we decided that 
Medicare rules for coverage of a heavy-duty walker with seat attachment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty walker with seat attachment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2022, billed with 
codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, and 81400. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed as required 
by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 26, 2022, billed with codes 81408, 81407, 81406, 81161, 81405, 81404, 81403, and 81400.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says the requested facet joint injections do not meet the 
Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found that the enrollee has a 
reported herniated cervical disc that would not be treated by the procedure, and she does not have documented 
facet pathology that would be treated by the procedure. The review has determined that the requested facet 
joint injections do not meet the Medicare LCD coverage criteria.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram performed  
May 20, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you should not be 
responsible for this amount. The Plan denied your request. The Plan says the copayment 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 $50 
copayment for in-network Medicare-covered x-rays.  
 
You have been asked to pay a $50 copayment for a diagnostic mammogram. A diagnostic mammogram falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and 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 waive the copayment for a diagnostic mammogram performed May 20, 2022.