Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for fall and scalp hematoma. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crutch substitute, lower leg platform, with or without 
wheels, each (E0118), provided on December 2, 2021. 
 
You asked the Plan to pay for a crutch substitute. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee scooter have not been met. Specifically, this item is not a covered benefit of Medicare or 
the Plan. Therefore, we decided that the Plan does not have to pay for a crutch substitute, lower leg platform, 
with or without wheels, each (E0118), provided on December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bronchoscopy (31624, 31627, 31628, 31629, 31654) 
provided November 19, 2020. 
 
You asked the Plan to pay for the bronchoscopy. You say that the services was medically necessary. The Plan 
denied your request. The Plan says the records do not support the services 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 codes 31624, 31627, 31628, 31629, & 31654 are not supported in the medical record. 
Specifically, only an x-ray report was provided. No procedure report was provided to detail these services. 
Based on this information, we decided that Medicare rules for coverage of the bronchoscopy have not been 
met. Therefore, we decided that the Plan does not have to pay for a bronchoscopy (31624, 31627, 31628, 
31629, 31654) provided November 19, 2020.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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 are medically stable and does not need physical medicine and rehabilitation 
(PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. You do not need intensive therapies, consisting of 
at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily 
therapy in an IRF.  While you may benefit from physical therapy (PT) and occupational therapy (OT), an uncomplicated hip 
fracture patient with low functional level does not need IRF and your rehabilitation can be safely provided at a 
lower intensity and alternate setting in an SNF. Your rehabilitation needs can be safely met in an alternate and 
lower intensity setting such as in an SNF. IRF admission is not medically necessary based on lack of medical 
complexity and lack of acute rehabilitation nursing needs and high mobility level. Your rehabilitation needs 
can be met at a lower intensity setting such as in a skilled nursing facility (SNF) for cognitive remediation. The 
document does not support the necessity for admission to 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood transfusion services provided on September 17, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for blood transfusion services. You say that medical services were approved by the 
PCP for treatment of leukemia. Referral was issued. The Plan denied your request. The Plan says enrollees 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 blood transfusion services provided on September 
17, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 the patient appears to be improving and should only require short-term additional 
acute care services that can safely be administered at the current facility for the time being. The patient 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 patient requires that are not already available and covered at the current facility. Transfer 
to LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a 
lower level of care may be considered when treatment has completed. 
 
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 LTACH services.
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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services 
(CMS) National Coverage Determinations Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 
stipulates that ventilators (E0465, E0466, and E0467) are covered for specific circumstances. 
 
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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. You have severe COPD, but there is no documentation of chronic CO2 retention on (arterial blood 
gas) ABG done while you are stable. The appeal note states you have failed bilevel positive airway pressure 
(bipap) but there is no documentation of this. It does not appear you have been tried on bipap with average 
volume-assured pressure support (AVAPS). Medicare does not cover a home ventilator when used as bipap. 
 
We looked at this physician's review, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on April 14, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct POS. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (0242U) provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician office visit provided on July 19, 2021, by an out-
of-network provider. 
 
You asked the Plan to pay for a physician office visit. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
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 a physician office visit provided on July 19, 2021, 
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on June 4, 2021, billed 
with codes 81185, 81286, 81400, 81413, 81414, 81442, and 81479. 
 
You asked the Plan to pay for the genetic testing panel as billed. You say that this should be covered. The Plan 
denied your request. The Plan says the testing was not billed correctly. 
 
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 codes billed on this claim are not supported. Specifically, no lab report with results from the 
testing was submitted for review. This means we are not able to confirm that the coding is correct for the 
services rendered. Based on this information, we decided that Medicare rules for coverage of the genetic testing 
panel as billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing panel provided on June 4, 2021, billed with codes 81185, 81286, 81400, 81413, 81414, 81442, and 
81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network 
(OON) provider on June 29, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on June 29, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), 
extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), limited oral evaluation - 
problem focused (D0140), and panoramic radiographic image (D0330) provided October 14, 2021. 
 
You asked the Plan to pay for the periapical x-ray, tooth extractions, limited oral exam and panoramic x-ray. 
You say that you don't understand the denial of these services. The Plan denied your request. The Plan says 
these services are not covered under your benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), extractions, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), limited oral evaluation - problem focused (D0140), and panoramic 
radiographic image (D0330) provided October 14, 2021.  
 
Your complaint about being dissatisfied with the lack of coverage provided by your dental plan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services (97811, 97810) rendered on October 6, 
2021. 
 You asked the Plan to pay for acupuncture services. You say that you have submitted explanations of benefits 
(EOCs) for three other dates of service the patient came in for and had the same codes and they were paid. The 
Plan denied your request. The Plan says since Medicare only covers up to 20 acupuncture visits per year, which 
the enrollee already used, this visit is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, since Medicare only covers up to 20 acupuncture 
visits per year, which the enrollee already used, this visit is not covered by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pay for acupuncture services (97811, 97810) rendered on October 6, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for podiatry services and a 
corticosteroid injection provided on November 2, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the podiatry services and injection. You say 
that you do not know why you are being charged an extra $6.40. The Plan denied your request. The Plan says 
the correct copayment and coinsurance was applied. 
 
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 
copayment for each podiatry visit. Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs, including 
injectable steroids. 
 
You have been asked to pay a $20 copayment for the podiatry services. The podiatry services fall within the 
Podiatry Services benefit category. You have also been asked to pay $6.40 for the injection, which is 20% of 
the allowed amount ($32.00 allowed amount x 20% coinsurance = $6.40). The injection falls within the 
Medicare Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment and 
coinsurance for podiatry services and a corticosteroid injection provided on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain without 
contrast material (70450) provided on October 2, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date. The Plan 
denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) 
edit exists between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed. However, an appropriate NCCI modifier was not billed with this PTP code 
edit. 
 
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 the computed tomography (CT) of the head or brain without 
contrast material (70450) provided on October 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology provided on May 12, 2021. 
 
You asked the Plan to pay for diagnostic radiology. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for diagnostic radiology provided on May 12, 2021.