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

 
We decided that the Plan does not have to pay for the inpatient hospital care billed for dates of service May 5, 
2023, to May 10, 2023. 
 
You asked the Plan to pay for the billed services. You say that the charges are not related to organ acquisition. 
The Plan denied your request. The Plan says the 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 code. 
 
We looked at the file and the rules. We find that the inpatient services were billed with diagnosis code Z21. 
This diagnosis was not billed with a present on admission (POA) code as required. The diagnosis code is not on 
the list of diagnoses that are exempt from reporting. Based on this information, we decided that Medicare rules 
for coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital care billed for dates of service May 5, 2023, to May 10, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued acute inpatient hospital care provided July 4, 2023, 
to July 11, 2023. 
 
You asked the Plan to pay for continued acute inpatient level of care. You say that the inpatient stay was 
medically necessary at the acute level of care. You also say that you would like the denial to be overturned and 
payment for the inpatient treatment to be rendered appropriately. The Plan denied your request. The Plan says 
beginning on July 4, 2023, there was a delay in making a decision to insert a feeding tube or placement into 
hospice. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital services are covered if the enrollees 
condition can be managed safely only in the inpatient hospital setting.  
 
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 continued acute inpatient level of care. Our 
reviewer says that the service was not medically necessary. Our physician reviewer found the review indicates 
that from June 20, 2023, through July 4, 2023, inpatient services were covered. Beginning on July 4, 2023, 
there was a delay in making a decision to insert a feeding tube or placement into hospice. The enrollee had 
severe problems swallowing. Her doctors had been unable to reach her guardian to make a decision regarding 
placing a feeding tube and/or going into hospice. Her care could have been appropriately provided in a non-
hospital setting. The review has determined that the continued inpatient level of care was not medically 
necessary from July 4, 2023, to July 11, 2023. The enrollee could have been reasonably discharged on July 4, 
2023. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued acute inpatient level of care have not been met. Therefore, we 
decided that the Plan does not have to pay for continued acute inpatient hospital care provided July 4, 2023, to 
July 11, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the oral device/appliance custom-fitted sleep apnea appliance (E0486) 
provided April 26, 2023. 
 
You asked the Plan to pay for the oral device. You say that you request that reconsideration of your claim along 
with the attached documentation.  The Plan denied your request. The Plan says that the Medicare rules for 
coverage have not been met. 
 
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 pay for the oral device. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the Polysomnography shows AHI of 10 events per hour and documented obstructive sleep 
apnea. The documentation shows the enrollee has hypertension. The Dentist and Medical Doctor (MD) 
documentation are provided. Thus, all criteria for the custom-fitted mandibular sleep apnea appliance 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 the oral device have been met. Therefore, we decided that the Plan has to pay 
for the oral device/appliance custom-fitted sleep apnea appliance (E0486) provided April 26, 2023.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ingrezza. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has had a positive response to this 
medication. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 14, 2023. 
 
You asked the Plan to pay for an office visit. You say that this service is supported in the records proving 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical bone-growth (osteogenesis) stimulator 
(E0748). 
 
You asked the Plan to pre-approve a bone-growth stimulator. You say that the requested services are a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for an osteogenesis 
stimulator have not been met. 
 
The Plan must follow Medicare rules. The rules say that that an electrical bone growth stimulator is covered 
only for the following indications: 
 
1. Nonunion of long bone fractures;  
 2. Failed fusion, where a minimum of 9 months has elapsed since the last surgery;  
 
3. Congenital pseudarthroses 
 
In this case, the case record indicates that an osteogenesis stimulator has been requested for a fusion patient. 
The record does not show that a minimum of 9 months has elapsed since the enrollee's last fusion surgery. 
Therefore, we decided that the Plan does not have to pre-approve an electrical bone-growth (osteogenesis) 
stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on September 05, 
2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you should not be billed for a 
follow-up office visit. The Plan denied your request. The Plan says this cost sharing was charged 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 $5 
copayment for in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $5 copayment for an office visit. This item/service falls within the in-network 
physician/practitioner services, including doctors office visits 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 an office visit provided on September 05, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 200 One Touch Ultra Test Strips (A4253). 
 
You asked the Plan to pre-approve the items. You say that you would like to request reconsideration of the 
denied test strips and that the services requested are medically necessary. The Plan denied your request. The 
Plan says the criteria for approval have not been met. 
 
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 items. Our physician reviewer 
found the record indicates that you have diabetes and are being treated with insulin. The record provided does 
not document the medical need for the additional quantity of test strips requested. The record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The 
elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 200 One Touch Ultra Test Strips (A4253).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing provided on August 8, 2023. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed. 
 
We looked at the file and Medicare rules. The documentation submitted does not contain a valid physician 
order or lab requisition for the testing provided in this case. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the testing provided on August 8, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a SPECT scan (78803). 
 
You asked the Plan to pre-approve a SPECT scan. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a SPECT scan is useful in the diagnosis of several 
clinical conditions. 
 
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 SPECT scan. Our reviewer says that 
the requested SPECT scan is medically reasonable and necessary in this case. Our physician reviewer found 
that a review of the available records showed that the enrollee has cognitive decline but also bilateral 
cogwheeling of the wrists and ataxia. As such, Parkinson's disease is in the differential. The requested SPECT 
dopamine transporter (DAT) scan is indicated to rule out Parkinson's disease in the enrollee. 
 
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 SPECT scan have been met. Therefore, we decided that the Plan has to pre-
approve a SPECT scan (78803).  
 
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 procedure code 86077 billed for date of service September 
14, 2023.  
 You asked the Plan to pay for procedure code 86077. You say that the records support the billed code. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service September 14, 2023.
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 LTACH services are necessary. The Plan 
denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 enrollee appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility.  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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (64624) provided on July 17, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis 
code is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for codes 64400, 64405, 64415, 64416, 
64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, 64449, 64454 and 64624 is limited 
to only certain diagnosis codes. 
 
We looked at the file and Medicare rules. Per LCA A57452, the billed diagnosis code. M17.11, is not covered 
for code 64624. 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 services (64624) provided on 
July 17, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a thoracic ESI. 
 
You asked the Plan to pre-approve a thoracic ESI. You say that your chronic pain is preventing your from 
participating in daily living activities. The Plan denied your request. The Plan says that the requested procedure 
does not meet the criteria necessary for approval. 
 
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 a thoracic ESI. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation shows the enrollee's condition meets the necessary criteria for a thoracic ESI 
to be approved. 
 
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 thoracic ESI have been met. Therefore, we decided that the Plan has to pre-
approve a thoracic ESI.  
 
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 visit (99204, 81002) provided on September 12, 
2023. 
 
You asked the Plan to pay for the office visit (99204, 81002). You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the office visit (99204, 
81002) provided on September 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on August 25, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on August 25, 2023.
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 that LTACH services are necessary. The 
Plan denied your request. The Plan says the criteria for an LTACH admission has not been met. 
 
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 enrollee appears to be improving with current treatment and should only require 
short-term additional acute care hospital services that can safely be provided at the current facility until more 
stable and appropriate for transfer to a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility.  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on January 17, 2023, 
through October 9, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the cost share is wrong. The Plan denied 
your request. The Plan says this cost sharing was charged correctly. 
 
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 $1,500 out-of-network deductible which applies to chiropractic 
services.  
 
The item or service you asked the Plan to pay for falls within the chiropractic services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 out-of-network 
deductible which applies to chiropractic services. This cost sharing is a contractual obligation that had not been 
met at the time the chiropractic services was received on January 17, 2023, to October 9, 2023. Therefore, we 
decided that the Plan does not have to pay for the chiropractic services provided on January 17, 2023, through 
October 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a user-adjustable heel-height addition (L5990) for a 
lower-extremity prosthesis. 
 
You asked the Plan to pre-approve a heel-height addition. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a user-adjustable heel-height feature (L5990) 
will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for 
coverage of a heel-height addition have not been met. Therefore, we decided that the Plan does not have to pre-
approve a user-adjustable heel-height addition (L5990) for a lower-extremity prosthesis.