Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve NutrEval testing panel. 
 
You asked the Plan to pre-approve NutrEval test. You say that this test will give you the ability to improve 
your health. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, 
because this testing is screening which is not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, NutrEval test, is being requested for screening purposes. Medicare does not 
cover this test for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
NutrEval testing panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on February 
16, 2022. 
 
You asked the Plan to pay for the special anesthesia service (99100). You say that code 99100 is payable under 
the contract. The Plan denied your request. The Plan says bundled services are not eligible for separate 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
  We find that CPT code 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on February 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device insertion for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is the best clinical option for this patient. 
The Plan denied your request. The Plan says that this service is considered experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device insertion for the enrollee.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar spine surgery. 
 
You asked the Plan to pre-approve lumbar spine surgery. You say that this is medically necessary and 
indicated. The Plan denied your request. The Plan says that the denial of authorization for this service is 
correct, because this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 lumbar spine surgery. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a failure of fusion and also foraminal stenosis with a new adjacent 
level disc herniation. Conservative measures have been tried and failed. There is computed tomography (CT) 
showing failure of previous fusion. There are new leg neurologic symptoms that have not responded to 
conservative measures. Revision spine surgery is appropriate and criteria for both decompression and fusion 
are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar spine surgery have been met. Therefore, we decided that the Plan has to 
pre-approve lumbar spine surgery.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home blood pressure monitor. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring provider is a participating 
provider, and they sent the specimen to your laboratory to process. The Plan denied your request. The Plan says 
the rendering and referring are both OON providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 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 the laboratory services provided on February 10, 
2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and 
services provided from February 15, 2022, to February 16, 2022. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation care. You say that you should not be 
responsible for this copayment, as you feel this stay could have been prevented. The Plan denied your request. 
The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your 
contract. 
 
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 $300 
copayment for each of the first five days of an inpatient hospital admission.  
 
You have been asked to pay a $300 copayment for inpatient rehabilitation care. Inpatient rehabilitation care 
falls within the inpatient hospital care benefit category, which requires a $300 copayment for each of the first 
five days of each admission. You were admitted for two days, but the day before you are discharged is your last inpatient day. 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 the inpatient rehabilitation admission and services provided from 
February 15, 2022, to February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on January 27, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and it was 
determined these services can be received 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 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 home health services provided on January 27, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on March 2, 2022, to March 
4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that a lower level of care would have been more 
appropriate. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found based on the medical records provided, at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided on March 2, 2022, to March 4, 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 pay for the office visits provided on January 27, 2022, and March 1, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visits. You say that you were referred to the OON provider and a 
procedure was covered on February 1, 2022, so these should be covered too. The Plan denied your request. The 
Plan says the rendering and referring providers are both OON providers and the only approved authorization 
for service was from January 28, 2022, to February 27, 2022; therefore, the dates of service on this appeal both 
fell outside of the approved authorization dates. 
 
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 the office visits provided on January 27, 2022, and 
March 1, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Homocysteine testing and Medical Nutrition Therapy 
provided on September 23, 2021. 
 
You asked the Plan to pay for Homocysteine testing and Medical Nutrition Therapy. The Plan denied your 
request. The Plan says the Plan requires utilization of network providers when possible and available and 
requires authorization for certain services. No medical necessity for an out-of-network provider such as an 
urgent or an emergent situation that has been documented.   
 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for Homocysteine testing and Medical Nutrition Therapy provided 
on September 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says you do not meet criteria for coverage of an IRF admission. 
 
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were 
admitted for an elective total hip replacement. Your medical problems are stable. You do not have complex 
nursing or rehabilitation needs.  
 
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. Medically necessary 
care can be provided in a different level of care. 
 
Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from 
an intensive rehabilitation therapy program provided in an IRF. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair. 
 
You asked the Plan to pre-approve a manual wheelchair. You say that it is hard for the enrollee to get around 
due to her immobility. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs are covered the enrollee has 
had a specialty evaluation.  
 
We looked at the file and Medicare rules. Review of the file shows that a physical therapy/occupational therapy 
note from the provider's office is only partially legible. Based on this information, we decided that Medicare 
rules for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on February 
15, 2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the bloodwork was ordered by 
your doctor and done the same day as your annual physical. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $0 
copayment for an annual physical exam. Any lab or diagnostic procedures ordered are not covered under this 
benefit and you pay your plan cost-sharing amount for those services separately. Your contract with the Plan also clearly says that you must pay a $45 copayment for lab services at an 
outpatient hospital. 
 
You have been asked to pay $37.57, which is less than the $45 copayment for the lab services. The lab services 
fall 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 laboratory services provided on February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided September 30, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing is not covered by Medicare 
or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the genetic testing services provided 
September 30, 2021, have been met. In this case, no clinical records were provided detailing the enrollees medical history. Without these clinical records, the medical necessity of the ordered testing cannot be 
established. Therefore, we decided that the Plan does not have to pay for the genetic testing services provided 
September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device insertion for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this service is considered experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device insertion for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on November 23, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-
74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the time spent providing this 
service is not noted in the medical record. Based on this information, we decided that Medicare rules for 
coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for 
critical care, first hour (99291) provided on November 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removable foot insert orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs an orthotic that 
accommodates his leg length discrepancy. The Plan denied your request. The Plan says the services are not 
covered. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
removable foot insert orthotics.