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

We decided that the Plan does not have to pay for the laboratory services (G0482 and 80307) provided April 3, 2023.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 laboratory services have been met. Medical records and a lab order were not provided to verify services. The documentation submitted did not include documentation to determine a relationship between the ordering provider and the enrollee at the time of service; therefore, the billed services cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0482 and 80307) provided April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure code D6058 for tooth #7. 
 
You asked the Plan to pre-approve the requested services. You say that the service was denied unfairly. The 
Plan denied your request. The Plan says the benefit for the requested service has been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
We looked at the file and the rules. Although the Plan offers a dental benefit in excess of Medicare coverage, 
certain limitations apply. The record shows that the benefit for code D6058 has been exhausted with the pre-
approval of teeth #8 and 9. Based on this information, we decided that the Plan's rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve procedure code D6058 for tooth 
#7.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair (PWC) repairs. 
 
You asked the Plan to pre-approve the PWC repairs. You say that the items should be covered. The Plan denied 
your request. The Plan says Medicare does not cover repairs when the expense for repairs exceeds the 
estimated expense for replacement of the wheelchair.  
 
The Plan must follow Medicare rules. Medicare rules say that if the expense for repairs exceeds the estimated 
expense of purchasing or renting another item of equipment for the remaining period of medical need, no 
payment can be made for the amount of the excess. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PWC repairs have not been met. Specifically, the cost of repairs exceeds the cost of 
replacement. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair (PWC) 
repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an OON provider.  
 
You asked the Plan to pre-approve the office visit. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says this service is available with in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office visit to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Dayspring nonpneumatic compression pump and garments. 
 
You asked the Plan to pre-approve a Dayspring nonpneumatic compression pump and garments. You say that 
you disagree with the Plan's denial. The Plan denied your request. The Plan says that the requested item 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 a Dayspring nonpneumatic compression 
pump and garments. Our reviewer says that the requested items/services are considered medically reasonable 
and necessary in this case. Our physician reviewer found the enrollee has chronic bilateral lower extremity 
lymphedema who has not had improvement with 4 weeks of conservative management. Based on Food and 
Drug Administration (FDA) clearance, and published trials, including the NILES trial, it would be an 
appropriate treatment modality for the enrollee. Therefore, the enrollee meets criteria for the requested item. 
 
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 Dayspring nonpneumatic compression pump and garments have been met. 
Therefore, we decided that the Plan has to pre-approve a Dayspring nonpneumatic compression pump and 
garments.  
 
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 pre-approve high dose rate electronic brachytherapy, skin surface 
application, per fraction, includes basic dosimetry, when performed (0394Tx10), therapeutic radiology 
simulation-aided field setting; simple (77280x10) and therapeutic radiology simulation-aided field setting; 
complex (77290). 
 
You asked the Plan to pre-approve electronic brachytherapy. You say that you are requesting reconsideration 
and submitted medical records for review. The Plan denied your request. The Plan says a review of current 
medical literature does not consider this service to be standard medical treatment for the enrollee's condition. 
 
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 electronic brachytherapy. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found electronic surface brachytherapy is not medically necessary for the treatment of basal 
cell cancer on the scalp in this enrollee. There are insufficient long-term efficacy and safety data to support this 
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 electronic brachytherapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve high dose rate electronic brachytherapy, skin surface application, per fraction, 
includes basic dosimetry, when performed (0394Tx10), therapeutic radiology simulation-aided field setting; 
simple (77280x10) and therapeutic radiology simulation-aided field setting; complex (77290).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is in a lot of pain and unable to get up 
alone and needs to stay in the skilled nursing facility in order to regain maximum function. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines because no longer requires skilled 
services on a daily inpatient basis and the continuation of SNF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage for negative pressure wound 
therapy electrical pump, stationary or portable (E2402). 
 
You asked the Plan to pre-approve continued wound vac therapy. You say that you really need this treatment, 
and you want answers as to why this did not get completely covered. The Plan denied your request. The Plan 
says under Medicare guidelines, this request is not medically necessary. 
 
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 continued wound vac therapy. 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 meet coverage criteria. The criteria outline the 
indications for non-continuance of coverage including a time limit of 4 months of therapy.  In this case there is 
documentation that despite over 4 months of treatment there has been evidence of deterioration with an 
increase in the wound size over the last 2 visits. Therefore, coverage criteria have not been met and unable to 
overturn the health plan determination.  
 
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 wound vac therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continued coverage for negative pressure wound therapy electrical pump, 
stationary or portable (E2402).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691) provided 
on June 6, 2023. 
 
You asked the Plan to pay for the UV light therapy system. You say that the item is medically necessary. The 
Plan denied your request. The Plan says there is no documentation of any psoriasis rash. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the UV light therapy system have not been met. Specifically, there is no documentation of any 
psoriasis rash is the records submitted. Therefore, we decided that the Plan does not have to pay for the 
ultraviolet (UV) light therapy system (E0691) provided on June 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service March 7, 
2023. 
 
You asked the Plan to pay for procedure code 22845. You say that there was a referral and prior authorization 
on file for this claim. The Plan denied your request. The Plan says payment for code 22845 is bundled into 
payment for code 22853. 
 
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 22845 
is a column II code to column I code 22853. 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 22845 billed for date of service March 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 20, 2023, billed with 
codes 81225, 81226, 81240, 81241, and 81328. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says panel testing should be billed using one 
CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 20, 2023, billed with codes 81225, 81226, 81240, 81241, and 81328.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want to go to inpatient rehabilitation to get 
stronger. The Plan denied your request. The Plan says your condition does not meet all of the requirements for 
inpatient rehabilitation admission. The Plan says services may be provided at a lower level of care.  
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 07, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were 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 subsequent nursing 
facility care provided on June 07, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from November 14, 2021, 
through November 19, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 the acute inpatient hospital care provided 
from November 14, 2021, through November 19, 2021. Our reviewer says that the documentation does support 
that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was 
admitted on November 6, 2021 and underwent a laparoscopic colostomy and bilateral above the knee 
amputations. He required maximal medical treatment including intravenous antibiotics, a peripherally inserted 
central catheter (PICC) line and wound care. He was discharged on November 19, 2021 when considered 
medically stable. The review has determined that the record showed that at the time of the inpatient admission 
it was reasonable for the admitting physician to expect that the enrollee's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights with supporting 
documentation of the enrollee's history and comorbidities, signs and symptoms, current medical needs, and risk 
of an adverse event. 
 
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 acute inpatient hospital care provided have been met.  
  
Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from  
November 14, 2021, through November 19, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on May 12, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on May 12, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs this care to regain 
maximum prior level of functioning. The Plan denied your request. The Plan says the enrollee's needs can be 
safely managed at the current facility until they are more stable for transfer to another level of care. 
 
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 is receiving appropriate care in their current acute care setting. The 
documentation does not support that LTACH services are medically appropriate at this time. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visits provided from July 3, 2023, to July 20, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the wound care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
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 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 from July 3, 2023, to 
July 20, 2023, by an out-of-network (OON) provider.