Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical and/or occupational therapy, there is not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Medically necessary care can be provided in a different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on November 16, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee encountered a dental abscess. 
The Plan denied your request. The Plan says the service is not covered under the medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The records provided show that the enrollee received care for a dental abscess. The services you are asking the 
Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollees teeth or the 
structures directly supporting the enrollees teeth. These are dental services that are not covered or paid for by 
Medicare. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 
16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a specialist office visit provided on January 
26, 2022. 
 
You asked the Plan to waive the deductible for a specialist office visit. You say that this claim should be paid. 
The Plan denied your request. The Plan says the deductible applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to specialist office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
Physician/Practitioner Services, Including Doctors Office Visits. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is a $500 deductible which applies to specialist office visits. This 
cost sharing is a contractual obligation that had not been met at the time a specialist office visit was received on 
January 26, 2022. 
 
 
 
 
 
  Therefore, we decided that the Plan does not have to waive the deductible for a specialist office visit provided 
on January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan has to pay for the splenectomy, thoracostomy, management of liver wound, and 
negative pressure wound therapy provided by an out-of-network provider on February 11, 2022. 
 
You asked the Plan to pay for the splenectomy, thoracostomy, management of liver wound, and the negative 
pressure wound therapy. You say that the enrollee was a trauma patient, therefore, no authorization was 
required. The Plan denied your request. The Plan says that no prior authorization was obtained. 
 
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson 
standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be 
such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of 
immediate medical attention would result in serious jeopardy to their health.  
 
We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with 
an average knowledge of medicine would reasonably expect the absence of immediate medical care to 
seriously jeopardize their health in this case. The medical record shows that the services were provided as part 
of the course of the enrollees emergency and trauma care Therefore, we decided that the Plan has to pay for 
the splenectomy, thoracostomy, management of liver wound, and negative pressure wound therapy provided by 
an out-of-network provider on February 11, 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 eyeglasses (V2020, V2100) purchased on January 6, 
2022. 
 You asked the Plan to pay for eyeglasses. You say that the enrollee called the Plan to verify benefits and was 
told that they were eligible for new eyewear starting on January 1, 2022. You feel that reimbursement should 
be provided for these services because the enrollee was misinformed. The Plan denied your request. The Plan 
says the enrollee previously used this benefit on January 10, 2020, which is less than two full rolling calendar 
years before the date in question. Therefore, the benefit was still exhausted when these eyeglasses were 
purchased, and the enrollee was not eligible for new vision benefits until January 10, 2022. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $200 once every two rolling calendar years. 
 
We looked at the file and the Plan's rules. The record shows that the enrollee previously received covered 
eyewear on January 10, 2020, which is less than two full rolling calendar years before the date in question. 
Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. 
Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2020, V2100) purchased on 
January 6, 2022.  
 
Your complaint about potential misinformation from a Plan representative regarding the availability of benefits 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the services provided on June 20, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services do not 
meet coding standards. 
 
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 argues that coding standards have not been met. However, the Plan has 
not provided any details regarding which coding rules have not been met. Without supporting documentation, 
the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services 
provided on June 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac rehabilitation-monitor provided on October 27, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for cardiac rehabilitation-monitor. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advanced. 
 
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 cardiac rehabilitation-monitor at issue in this appeal. The Plan did not 
pre-approve the cardiac rehabilitation-monitor 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 cardiac rehabilitation-
monitor provided on October 27, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovascular revascularization for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the leg ultrasound did not show blockage that needs a surgical 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 the documentation does not support the reasonableness and medical necessity of the treatment in 
question due to a lack of clinical clarity. The documentation provided does not provide any details with respect 
to the patient's complaint. There is unsatisfactory detail with respect to nature of symptoms, location, and 
reproducibility. Additionally, there is a complete disconnect between the arterial blood indices (ABIs) and the 
arterial duplex study. Additionally, there is a conspicuous absence of a pulse examination.  As noted by the 
health plan, treatment of an isolated single tibial stenosis is unlikely to be appropriate for this patients 
condition as currently documented. 
 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 endovascular revascularization for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on September 9, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing services provided on September 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the established patient office visit (99214) provided on November 27, 
2021. 
 
You asked the Plan to pay for the established patient office visit. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says that this claim has not 
been billed with a correct bill type. 
 
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 has denied payment for the claim based on an incorrect bill 
type. There is no indication from the Plan on what makes this an incorrect bill type. The Plan has failed to 
sufficiently support their denial with language explaining why the bill type is incorrect. Therefore, we decided 
that the Plan has to pay for the established patient office visit (99214) provided on November 27, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services (00400) provided on February 11, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that the claim at issue has been incorrectly denied. 
The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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 case record does not explain or support the Plan's denial 
rationale. The Plan does not explain why an anesthetist would not be capable of providing the services at issue. 
It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been substantiated so we 
must find in your favor. Therefore, we decided that the Plan has to pay for anesthesia services (00400) 
provided on February 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on November 
2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable 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 CPT code 81479 is not supported in the medical record. Specifically, when a laboratory assays 
two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. 
A panel constitutes a single procedural code, so one code must be submitted for the panel. The testing provided 
was billed with this code as well as others on a different claim form for the same date of service. This means 
the services were billed incorrectly. 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 coded 81479 provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital breast tomosynthesis (77061) provided on January 
10, 2022. 
 
You asked the Plan to pay for a digital breast tomosynthesis. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of a digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not 
have to pay for a digital breast tomosynthesis (77061) provided on January 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone growth device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion 
of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs 
have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the 
electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs 
separated by a minimum of 90 days.  
 
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 device. Our reviewer says that the 
requested device is not medically reasonable and necessary. Our physician reviewer found not enough time has 
passed to establish the diagnosis of non-union of the foot fracture. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a bone growth device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infrared therapy (97026) provided on April 15, 2021, and 
April 19, 2021. 
 
You asked the Plan to pay for the infrared therapy. The Plan denied your request. The Plan says infrared 
therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. 
 The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for the infrared therapy (97026) provided on April 15, 2021, and April 19, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray provided on January 6, 2022. 
 
You asked the Plan to pay for an x-ray. You say that you are requesting reconsideration for the radiology 
service. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 
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 x-ray provided on January 6, 2022.