Persius/hicric huggingface dataset:
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 the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the records do not show that the enrollee needs 
continued treatments and care that can only be given at the hospital setting. The enrollee's continued care needs 
include therapy. When the enrollee is ready to leave the hospital, they can safely receive this care in another 
setting, such as an inpatient rehabilitation facility or a skilled nursing facility. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional occupational therapy visits for the 
enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the health plan has no contractual obligation to cover services that are not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. The requested visits are not medically reasonable or necessary. Our physician reviewer found that 
based on the available records, the enrollee appears to be very limited due to dementia, with limited ability to 
participate in therapy. After the now 12 approved occupational therapy treatments records do not support that 
the complexity of the patients conditions and her ability to participate are such that the skills of a professional 
therapist are required to achieve further improvement in the patient's symptoms or functional status. Further 
utilization of the home exercise program and assistance from caregivers appears appropriate at this point. 
Passive range of motion exercise does not require the expertise of a professional skilled occupational therapist. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve ten additional occupational therapy visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71260 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 71260. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 71260 is bundled into payment for 
code 71275. 
 
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 71260 
is a column II code to column I code 71275. 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 71260 billed for date of service February 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for hyaluronan on November 17, 2021. 
 
You asked the Plan to waive the cost share for hyaluronan. You say that you were not told there would be a 
cost share applied to this procedure. The Plan denied your request. The Plan says the cost share was 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 drugs that usually arent self-administered by the patient and are injected or infused while 
getting physician, hospital outpatient, or ambulatory surgical center services.  
 
You have been asked to pay $516.08 for hyaluronan. Hyaluronan 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 cost share for hyaluronan on November 17, 
2021.  
 
Your complaint about being given incorrect information by your provider about your cost share responsibility 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on April 26, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the lab services provided on April 26, 2022 by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77067 billed for date of service January 26, 
2022. 
 
You asked the Plan to pay for procedure code 77067. You say that the medical records support payment. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 17, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for procedure code 77067 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 77067 billed for date of service 
January 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor and supplies. 
 
You asked the Plan to pay for the continuous glucose monitor and supplies. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider did not 
write the order for the continuous glucose monitor. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the medical records indicate that the enrollee is only on insulin 1 time a day and does 
not adjust their dosage. There is contradictory information in the case file that does not support the equipment 
as ordered. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor and 
supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi electric hospital bed, with any type side rails, 
with mattress (E0260). 
 
You asked the Plan to pre-approve the hospital bed. You say that the enrollee has to have his elevated more 
than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease and problems with 
aspiration. The Plan denied your request. The Plan says the requested semi-electric hospital bed is not 
medically necessary 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient:  
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 hospital bed. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the documentation doesnt support that the enrollee has a condition that requires 
frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent 
contractures or avoid respiratory infections in a way that an ordinary bed is not able to. 
 
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 hospital bed have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the semi electric hospital bed, with any type side rails, with mattress (E0260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed without the appropriate modifier. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, these codes 
are assigned a PC/TC indicator of 1. This means that modifier -26 is required in this case, as the services were 
billed with place of service 22. 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 lab services 
provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
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.   
 
 
 The records show that you do not suffer from diabetic foot disease and you do not wear a leg brace.  
Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics 
for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder genetic testing services (0012M) 
 
You asked the Plan to pay for the CxBladder testing. 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 there is non-coverage policy in place that was 
reaffirmed for Current Procedural Terminology (CPT) codes 0012M and 0013M for CxBladder. Based on this 
information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the CxBladder genetic testing services (0012M)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need intense physical and occupational therapy 
provided by an IRF to be able to be independent at home. The Plan denied your request. The Plan says the 
enrollee does not have complex rehabilitation, medical, or nursing needs. The enrollee does not need to be 
assessed medical and functionally face-to-face by a rehabilitation doctor, at least 3 days per week. The enrollee 
rehabilitation does not require a team approach management. The enrollee's needs can be met at an alternative 
level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours a day, 5 days a week of therapies with multidisciplinary 
approach in an IRF. The enrollee needs gait training only with a prosthesis. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While the enrollee would benefit from physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF 
or continued in-home therapies. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (81479) provided on April 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that services billed 
with modifier -GZ are not covered. 
 
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 this service is not payable because it was billed with the -
GZ modifier. However, the records do not show that the code in question was billed with modifier -GZ. 
Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the 
Plan has to pay for the services (81479) provided on April 13, 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 procedure code 71046-26-76 billed for date of service 
January 4, 2022. 
 
You asked the Plan to pay for procedure code 71046-26-76. You say that the patient had multiple exams on this 
date of service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on May 12, 2022. You billed the second claim with modifier 76, indicating a repeat 
procedure.  However, the medical records do not support that code 71046 was performed twice on the same 
date. Based on this information, we decided that the Medicare rules for procedure code 71046-26-76 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 71046-26-76 billed for 
date of service January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) device and 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM device and supplies. You say that the enrollee is on insulin and 
requires close monitoring for hypoglycemia. The Plan denied your request. The Plan says the enrollee does not 
meet prior authorization criteria. 
 
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 the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitoring (CGM) device and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an injection, anesthetic agent(s) and/or steroid; 
transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you are in pain and cannot have 
surgery due to a stroke. The Plan denied your request. The Plan says the requested injection does not meet 
criteria for approval. 
 
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 an epidural steroid injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not support the medical necessity of the requested 
injection. The documentation does not reveal failure of all conservative treatment such as physical therapy 
prior to this injection. The request for a second injection was submitted on 7/21/22 which was only 21 days 
later from the previous injection. The documentation does not reveal an objective physical examination with 
evidence of radiculopathy on physical exam in the proposed area of injection. The documentation does not 
support the request for a repeat procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an injection, anesthetic agent(s) and/or steroid; transforaminal epidural, with 
imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay from February 16, 2022, to 
March 1, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible to pay 
this. The Plan denied your request. The Plan says the cost share 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 for each SNF stay you 
must pay $0 per day for days 1 to 20; $188 per day for days 21 to 100.  
 
 
 
 
 
 You have been asked to pay $2444 ($188/day x 13 days) for a SNF stay. A SNF stay falls within the Skilled 
Nursing Facility Care 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 skilled 
nursing facility (SNF) stay from February 16, 2022, to March 1, 2022.