Persius/hicric huggingface dataset:
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 enrollee's needs cannot be provided 
at a lower level of care. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says the enrollee does not meet all the requirements for an LTACH admission.  
 
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 there is no documentation provided indicating medical necessity for admission to an 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. 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 Plan. 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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 9, 2022, to 
October 8, 2022. 
 You asked the Plan to pay for the home health services. You say that the Plan has not provided any means by 
which to submit the NOA. The Plan denied your request. The Plan says the NOA was not received. As such, 
this final claim was correctly denied. The Plan says that although you claim that a NOA was submitted, none 
has been received. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, he NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from September 9, 
2022, to October 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81351) provided on March 16, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab services 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 lab services (81351) provided on March 16, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 6, 2023, to April 
4, 2023. 
 You asked the Plan to pay for the home health services. You say that the Plan did not require NOAs in the past. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 6, 2023. The NOA was not received by the Plan until June 21, 2023. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided from 
March 6, 2023, to April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the US-IGRT. 
 
You asked the Plan to pre-approve the US-IGRT. You say that the service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says there is not enough evidence that this type of radiation 
therapy guidance is needed or effective 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 the US-IGRT. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that due to limited available good quality data, the decision to use US-IGRT is still a clinical 
uncertainty. 
 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 US-IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the US-IGRT.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (E0955, E1002, E2310, E2361, E2601, E2620, K0856)  

You asked the Plan to pre-approve a group 3 power wheelchair and accessories. 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 power mobility devices are covered when specific 
criteria are 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 a group 3 power wheelchair and 
accessories. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not indicate that the enrollee has any pressure injuries or requires intermittent 
catheterization of the bladder or have spasticity that would necessitate power tilt or recline. Although the 
enrollee's condition may meet criteria for a power wheelchair, the criteria for this specifically requested power 
wheelchair with multiple power options including power tilt and recline are not 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 a group 3 power wheelchair and accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option and 
accessories (E0955, E1002, E2310, E2361, E2601, E2620, K0856)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine remote retinal imaging provided on December 1, 
2022. 
 
You asked the Plan to pay for routine retinal imaging. You say that this procedure was recommended by your 
eye doctor, and you did not realize it would not be covered. The Plan denied your request. The Plan says this is 
not a covered service and was not billed with an appropriate code. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The requested retinal imaging was performed during a routine vision 
exam with routine eye refraction. This is not a service which is covered by your vision benefit. Based on this 
information, we decided that the Plan's rules for coverage of remote retinal imaging have not been met. 
Therefore, we decided that the Plan does not have to pay for routine remote retinal imaging provided on 
December 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory pathogen panel provided on March 21, 2023, 
billed with multiple codes.  
 
You asked the Plan to pay for the respiratory pathogen panel as billed. You say that this should be paid due to 
medical necessity.  The Plan denied your request. The Plan says this should be billed with one unit of service.  
 
The Plan must follow Medicare rules. Medicare rules say that a respiratory pathogen panel test must not be 
unbundled and billed as individual components regardless of the fact that the panel reports multiple individual 
pathogens and/or targets.  
 
We looked at the file and Medicare rules. This panel was not billed with a single unit of a panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen 
panel as billed have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory 
pathogen panel provided on March 21, 2023, billed with multiple codes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 87186) rendered on 
January 18, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 87186 (1 unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87186 is "Susceptibility studies, antimicrobial agent; 
microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-
antimicrobial, per plate." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the culture did not grow any 
organisms and therefore no susceptibility studies were completed. 
 
We looked at this coder's review, the file, and Medicare rules. 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 laboratory services (procedure code 87186) rendered on January 18, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 2, 2022, to 
October 1, 2022. 
 You asked the Plan to pay for the home health services. You say that you originally submitted the claim in the 
wrong format, which resulted in the late NOA.  You said that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says the NOA was not received timely. As such, this 
final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is August 3, 2022. The NOA was not received by the Plan until February 16, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from September 2, 2022, to October 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 24 additional PT visits. You say that the records provided support the need 
for the PT visits which remain in dispute. The Plan denied your request. The Plan says the additional PT visits 
in dispute are not medically necessary. 
 
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 24 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as 
specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The 
records do not demonstrate that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or 
by or under the supervision of a therapist beyond what was already approved. The requested services are not 
part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. The enrollee has had extensive therapy approved with additional therapy 
approved to ensure instruction in a home exercise program. The enrollee does not require the 24 remaining 
therapy sessions with a skilled therapist and can safely transition to a home exercise program.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 24 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on May 24, 2023, billed with 
codes 87481, 87500, 87640, 87641, 87651, 87653 and 87798. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was medically necessary and 
is supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on May 24, 2023, billed with codes 87481, 87500, 87640, 87641, 87651, 87653 and 87798.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental implant services (D6010, D6056 and D6053) provided 
from March 9, 2023, to March 22, 2023. 
 
You asked the Plan to pay for dental implant services. You say that these services were necessary, and you 
confirmed before treatment that your benefits covered these services. The Plan denied your request. The Plan 
says their records indicate that you were told that dentures are covered but you did not ask about specific codes, 
implants or abutments during your call with customer service. Implants and any related services are not 
covered by your dental benefit. 
 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 dental 
implant services (D6010, D6056 and D6053) provided from March 9, 2023, to March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiography (TTE) rendered on April 
28, 2023. 
 
You asked the Plan to pay for the services. You say that these services were provided in good faith. The Plan 
denied your request. The Plan says there was no clinical reason for this to be done, as the records do not show 
chest pain. 
 
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that at issue is the medical necessity of a TTE, in the absence of any cardiac signs or symptoms or 
abnormal findings on physical exam. As such, the rationale for the TTE is not clear from the documentation 
provided. In summary, there is no supportive evidence for the medical necessity of TTE in this enrollee's 
clinical management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a transthoracic echocardiography (TTE) rendered on April 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home visit provided on March 30, 2023.  
 
You asked the Plan to pay for the home visit. You say that this visit should be paid.  The Plan denied your 
request. The Plan says this was not billed with the correct place of service as the enrollee was a registered 
inpatient. 
 
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 home visit have been met. No 
medical records were submitted to support that the services were rendered. In addition, the enrollee's claim 
history indicates that they were inpatient on the date of service in question and not in the home. Therefore, we 
decided that the Plan does not have to pay for the home visit provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the resin-composite filling on tooth #12 (D2392) provided on February 
6, 2023. 
 
You asked the Plan to pay for the filling. You say that this service should be covered. The Plan denied your 
request. The Plan says that payment was made on the least expensive alternative treatment. 
 
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 did not provide medical records regarding the filling of tooth #12. 
Without the medical records we are unable to determine if the less expensive alternative would have produced 
a professional satisfactory result compared to the billed amalgam filling. Therefore, we decided that the Plan 
has to pay for the resin-composite filling on tooth #12 (D2392) provided on February 6, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular compression unit (VCU) provided as a rental 
from January 13, 2023, through February 2, 2023, billed with code E0217. 
 
You asked the Plan to pay for the VCU rental. You say that this compression and heating units is medically 
necessary to reduce the risk of postoperative complications and pain. The Plan denied your request. The Plan 
says this is not covered by Medicare.  
 
The Plan must follow Medicare rules. Medicare rules say that the equipment described by code E0217 will be 
denied as not medically necessary.  
 
We looked at the file and Medicare rules. It is noted that the code E0217 may not be appropriate for the type of 
unit provided. However, there is no Medicare coverage for the coded item E0217. Based on this information, 
we decided that Medicare rules for coverage of the VCU rental have not been met. Therefore, we decided that the Plan does not have to pay for the vascular compression unit (VCU) provided as a rental from January 13, 
2023, through February 2, 2023, billed with code E0217.