Persius/hicric huggingface dataset:
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 services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee has reached their 100-day benefit limit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from March 7, 2023, 
through July 5, 2023. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 9, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the test should not be 
included in the dialysis rate. The Plan denied your request. The Plan says Medicare does not separately pay for 
ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable.  
 
 Laboratories should bill the facility directly for laboratory services as they are considered part of the composite 
rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay 
for the laboratory services related to end-stage renal disease (ESRD) provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair (E0138), hospital bed (E0297), 
portable/stationary oxygen concentrators (POC) (E0443), and humidifier (E0424), provided on January 8, 
2022, through January 29, 2022. 
 
You asked the Plan to pay for the wheelchair, hospital bed, POC, and humidifier. You say that the items should 
be covered. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.   
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the wheelchair (E0138), hospital bed (E0297), 
portable/stationary oxygen concentrators (POC) (E0443), and humidifier (E0424), provided on January 8, 
2022, through January 29, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $45 more for the eyewear. We decided that the Plan does not have to pay 
in full for the eyewear.  
 
  You asked the Plan to pay more for the progressive lens (V2781), deluxe lens feature (D2702), polycarbonate 
or equal lens (V2784), anti-reflective coating (V2750), and vision item or service (V2799) provided on 
February 20, 2023. You say that you would have never agreed to this cost because you knew you could not pay 
it. You also say that you would like this to be reconsidered and written off for regular lenses. The Plan says that 
this claim was processed correctly. 
 
We decided that the Plan has to pay $45 more for the eyewear.  
 
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. The Plan offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. Specifically, the record shows that the Plan only paid $55 toward this 
purchase. Write-offs and disallowed amounts are not benefits that are actually paid by the Plan. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have been met. The remaining 
balance of your eyewear benefit is $45. Therefore, we decided that the Plan has to pay $45 more for the 
eyewear.  
 
We also decided that the Plan does not have to pay in full for the eyewear. 
 
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. The Plan offers a $100 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses. 
 
We looked at the file and the Plan's rules. We decided that the Plan must pay the remaining $45 of your 
eyewear benefit. Once this amount is paid, your eyewear allowance will be exhausted. Based on this 
information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we 
decided that the Plan does not have to pay in full for the eyewear. 
 
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 a foam mattress (E0272) purchased from a non-participating 
provider who is not certified with Medicare, on December 23, 2022. 
 
You asked the Plan to pay for a foam mattress. You say that the item should be covered. The Plan denied your 
request. The Plan says the item obtained  was rendered by a provider who is not under contract with the health 
plan and is not certified for Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a foam mattress (E0272) purchased from 
a non-participating provider who is not certified with Medicare, on December 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  a Gastrointestinal Pathogen (GIP) Panel (87507) collected 
on December 12, 2022. 
 
You asked the Plan to pay for a GIP panel. You say that the service was medically necessary. The Plan denied 
your request. The Plan says there is no documentation of severe or persistent diarrhea and no documentation of 
immunocompromise. 
 
The Plan must follow Medicare rules. Medicare rules say that GIP panels utilizing NAATs, 12 or more targets, 
are medically reasonable and necessary for the evaluation of Medicare beneficiaries with an 
immunocompromising medical condition with acute or persistent diarrhea.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a GIP panel have not been met. Specifically, there is no documentation of severe or persistent 
diarrhea and no documentation of immunocompromise. Therefore, we decided that the Plan does not have to 
pay for  a Gastrointestinal Pathogen (GIP) Panel (87507) collected on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace. 
 
You asked the Plan to pay for a back brace.. You say that the item should be covered. The Plan denied your 
request. The Plan says payment is not allowed based on the review of the claim information showed this 
service was related to a prohibited telemarketing contact. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact 
by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of a back brace. have 
not been met. Therefore, we decided that the Plan does not have to pay for a back brace.
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 the services are necessary for the enrollee to receive 
rehabilitation to maximize their potential to return to their previous level of independence. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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 enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided from May 26, 2022, to May 28, 
2022, at the DRG originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical record clearly supports the clinical diagnosis and the DRG assignment as billed. You say that the 
medical records should be reviewed, and payment of the entire claim should be approved. The Plan denied your 
request. The Plan says that diagnosis code T82.9XXA is not supported, which resulted in a DRG change. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with diagnosis code T82.9XXA, defined as unspecified 
complication of cardiac and vascular prosthetic device, implant and graft, initial encounter. 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 inpatient hospital services at the DRG originally billed. 
Our reviewer says that the documentation supports diagnosis code T82.9XXA. Our physician reviewer found 
the history of present illness explicitly states that the inability to access the vascular graft was the reason for 
presentation to the hospital, which did require clinical evaluation of the graft. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient 
hospital services provided from May 26, 2022, to May 28, 2022, at the DRG originally billed.  
 
  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 pre-approve non-sterile gloves and adult diapers.  
 
You asked the Plan to pre-approve incontinence supplies. You say that the items should be covered. The Plan 
denied your request. The Plan says these are non-reusable hygienic items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves and adult 
diapers.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computer-assisted surgical navigation (20985) for hip 
surgery on February 21, 2023. 
 
You asked the Plan to pay for computer-assisted surgical navigation. You say that this was medically 
necessary. The Plan denied your request. The Plan says this service was 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 pay for computer-assisted surgical navigation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature 
that shows this request to be an effective and/or safe treatment for the noted pathology. The clinical benefits 
(including ultimate outcomes of functional improvement and pain reduction with computer navigation) have 
not been long term large volume literature established. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pay for computer-assisted surgical navigation (20985) for hip surgery on 
February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 2, 2022, billed 
with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272. 
 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 
November 2, 2022, billed with codes 81201, 81292, 81295, 81298, 81307, 81317, 81321, 81351, and 81272.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve water vapor therapy/Rezum procedure (53854).  
You asked the Plan to pre-approve water vapor therapy/Rezum procedure. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. 
 
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 water vapor therapy/Rezum procedure. 
Our reviewer says that you do not meet coverage criteria. Our physician reviewer found the records do not 
show that you have a maximum urinary flow rate (Qmax) of less than or equal to 15 mL/s, failure, 
contraindication or intolerance to at least three months of conventional medical therapy for BPH and is a poor 
candidate for other surgical interventions for BPH due to underlying disease, or at high risk of bleeding. In 
addition, the records show that the prostate size is 87 gm which is above the required 30-80 gm size required 
for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of water vapor therapy/Rezum procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve water vapor therapy/Rezum procedure (53854).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0483 billed for date of service January 24, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the drug screen provides valuable information to 
the physician. The Plan denied your request. The Plan says the test exceeds the needs of the enrollee. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The medical records provided 
show that the enrollee has been taking medications as prescribed and the enrollee has not exhibited any signs of 
problematic behaviors or abuse. 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 procedure code 
G0483 billed for date of service January 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3020).  
 
You asked the Plan to pay for foot orthotics. You say that the item is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
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.   
 
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 pay for foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pool membership (A9270) purchased on February 2, 
2023. 
 
You asked the Plan to pay for the pool membership. You say that you received a magazine from the Plan with 
the front page showing a gentleman wearing swim goggles, as well as an article stating you should choose the 
exercise that matches your abilities and needs, and it includes swimming as one of the choices. You also say 
that your cardiologist thought swimming was a fantastic choice for you, and you would like to be reimbursed 
for the membership. The Plan denied your request. The Plan says a pool membership is not considered to be a 
qualified health club or fitness facility. 
 The rules say that Medicare does not cover gym benefits. However, the Plan offers a Wellness Allowance 
benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a Wellness Allowance benefit in excess of Medicare coverage, pool memberships are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
pool membership (A9270) purchased on February 2, 2023.