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

 
We decided that the Plan does not have to pre-approve a total right hip arthroplasty. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation of physical therapy provided for hip pain. More conservative measures are 
needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a total right hip arthroplasty.
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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met  
 
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 do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. Medically necessary care can be provided in a different level of care. There is 
no reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 power operated vehicle (K0800). You say that the requested 
group 1 power operated vehicle is medically necessary. The Plan denied your request. The Plan says the 
enrollee does not meet criteria for a group 1 power operated vehicle. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 1 power operated vehicle 
(K0800). Our reviewer says that the enrollee does not meet criteria for a group 1 power operated vehicle. Our 
physician reviewer found there is a lack of clinical documentation supporting that the enrollee is unable to 
independently ambulate in the home and accomplish his daily activities. He is currently ambulating with the 
assistance of a walker. While he may be at increased risk for falling with the assistance of a walker, there is no 
indication that he cannot use a manual wheelchair for mobility. Additionally, there is insufficient 
documentation indicating that the enrollee can safely use the requested power scooter within his home. He is 
noted to have momentary lapses of cognition and an electroencephalogram (EEG) was ordered. 
 
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 1 power operated vehicle (K0800) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 1 power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foreign medical services provided from June 14, 2023, to 
June 18, 2023. 
 
You asked the Plan to pay for the foreign medical services provided on June 14, 2023. You say that you have 
sent in all of the information that you have. You say that the entire cruise was within the United States with the 
exception of where it took off from. You also say that you feel these services should be covered. The Plan 
denied your request. The Plan says there were no medical records or proof of payment provided to support 
reimbursement of the services. 
 
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 medical services have been met. 
Specifically, there were no medical records provided to support the services should be covered. Therefore, we 
decided that the Plan does not have to pay for the foreign medical services provided from June 14, 2023, to 
June 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical extraction (D7210) provided on May 30, 2023. 
 
You asked the Plan to pay for D7210. You say that you would like the Plan to reconsider payment for this 
extraction. The Plan denied your request. The Plan says the rendered dental service is not a covered 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 a surgical 
extraction (D7210) provided on May 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network mental health services 
provided on July 27, 2023, to August 15, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network mental health services. You say that you want 
this to be reviewed because the amount is too high. 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 45% 
coinsurance for outpatient mental health services. 
 
You have been asked to pay 45% coinsurance for out-of-network mental health services. This item/service falls 
within the outpatient mental health services 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. The amount you owe is $110.51. Therefore, we decided that the Plan does 
not have to waive the coinsurance for out-of-network mental health services provided on July 27, 2023, to 
August 15, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary.  The Plan denied your 
request. The Plan says that this is not necessary for your condition.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Prolia. Our reviewer says that the 
requested use of Prolia is supported and medically necessary. Our physician reviewer found Prolia was 
approved in 2018 for treatment of glucocorticoid-induced osteoporosis (GIOP) in men and women at high risk 
of fracture who are either initiating or continuing systemic glucocorticoids in a daily dosage equivalent to 7.5 
milligrams or greater of prednisone and who are expected to remain on glucocorticoids for at least 6 months. 
Patients are considered at high risk of fracture if they have a history of osteoporotic fracture, multiple risk 
factors for fracture, or failed or cannot tolerate other available osteoporosis therapy. In this case, you have 
osteoporosis. The documentation supports that the Prolia is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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 the definitive urine drug testing (UDT) for 8-14 drug classes 
(G0481) provided on February 2, 2023. 
 
You asked the Plan to pay for the definitive urine drug testing (UDT) for 8-14 drug classes (G0481). You say 
that the urine drug testing provided was medically necessary. The Plan denied your request. The Plan says the 
enrollee did not meet criteria for the provided urine drug testing (G0481). 
 
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 definitive urine drug testing (UDT) for 
8-14 drug classes (G0481). Our reviewer says that the enrollee did not meet criteria for the provided urine drug 
testing (G0481). Our physician reviewer found the enrollee is with chronic low back pain on opioid treatment. 
A request was made for definitive urine drug testing (UDT) for 8-14 drug classes (G0481). However, the 
provided documentation did not reveal unexpected results from a presumptive urine drug screen or evidence of 
drug abuse/misuse to justify confirmation testing of any kind. Also, the number of drug classes was excessive 
as only 3 classes would have been applicable to 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 the definitive urine drug testing (UDT) for 8-14 drug classes (G0481) have not 
been met. Therefore, we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) 
for 8-14 drug classes (G0481) provided on February 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87641-59, 87500-59, 87798-59) 
provided August 10, 2023. 
 
You asked the Plan to pay for the 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87641 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. The definition of code 87500 is infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus 
species van A, van B), amplified probe technique. The definition of code 87798 is infectious agent detection by 
nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
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 found for code 87641, the 
documentation submitted was reviewed and does not meet criteria. The medical record did not include a 
physician order as well as, test was not found in laboratory report, and therefore, cannot be verified. For code 
87500, the documentation submitted was reviewed and does not meet criteria. The medical record did not 
include a physician order as well as, test was not found in laboratory report, and therefore, cannot be verified. 
For code 87798, the documentation submitted was reviewed and does not meet criteria. The medical record did 
not include a physician order as well as, procedure code represents a "not otherwise specified test. In this case, 
procedures billed under this code cannot be verified. 
 
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 the laboratory services (87641-59, 87500-59, 87798-59) provided August 10, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on 
August 2, 2023. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that the services at issue have been 
reported correctly. The Plan denied your request. The Plan says 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 CPT code. 
 We find that CPT code 90791 is not supported. Specifically, the claim in dispute has been billed on bill type 
130. The frequency code of this bill type is 0, which indicates nonpayment/zero claims. The services at issue 
are not payable when billed on bill type 130. Based on this information, we decided that Medicare rules for 
coverage of a psychiatric diagnostic evaluation have not been met. Therefore, we decided that the Plan does not 
have to pay for a psychiatric diagnostic evaluation (90791) provided on August 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (83789-59) provided July 28, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
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 83789 is a column II code to column I code G0480; however, 83789 
was billed with a modifier.  
 
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 laboratory service. Our reviewer found the 
documentation submitted was reviewed and does not meet criteria. The laboratory report describes specimen 
validity results; Urine - Creatinine; Urine - Specific Gravity Level; Urine - PH Level; Urine - Oxidants in 
addition to urine drug testing.  Per Centers for Medicare & Medicaid Services (CMS): Providers performing 
validity testing on urine specimens utilized for drug testing shall not separately bill the validity testing. For 
example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to 
confirm that a urine specimen is not adulterated, this testing is not separately billed. Therefore, billing this 
procedure separately with modifier denied appropriately. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (83789-59) provided July 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided from April 8, 2022, to  
November 30, 2022. 
 
You asked the Plan to pay for massage therapy. You say that you have suffered from chronic low back pain for 
several years and wanted to try massage therapy to see if it would provide any relief from your pain. The Plan 
denied your request. The Plan says massage therapy is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided from April 8, 2022, to  
November 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Remote Patient Monitoring (RPM) provided on April 30, 
2023. 
 
You asked the Plan to pay for the Remote Patient Monitoring (RPM). You say that this 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 Remote Patient 
Monitoring (RPM) provided on April 30, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on June 14, 2023, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the mental health services provided on June 14, 2023, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
harness (E2313), expandable controller (E2377), light-emitting diode (LED) light kit (K0108), and self-
leveling cup holder (K0108). 
 
You asked the Plan to pre-approve an electronic connection, expandable controller harness, expandable 
controller, LED light kit, and self-leveling cup holder. You say that you would like the medical documentation 
to support the need of the custom medical equipment being requested for the enrollee to be reviewed. The Plan 
denied your request. The Plan says the requested electronic connection, expandable controller harness, and 
expandable controller exceeds the enrollee's need and is not reasonable and necessary per Medicare criteria. 
The Plan also says that the LED light kit and cup holder do not serve a medical purpose and cannot be covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection, expandable 
controller harness, and expandable controller. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 
hemiparesis, but is able to feed themself. Our reviewer also found that the enrollee has adequate strength to 
manage standard power drives. 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. The LED light kit and self-leveling cup 
holder do not serve purposes that are primarily medical in nature. These items are available to the general 
public and would be helpful even to those who are not sick or injured. Based on this information, we decided 
that Medicare rules for coverage of an electronic connection, expandable controller harness, expandable 
controller, LED light kit, and self-leveling cup holder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311), expandable controller harness (E2313), 
expandable controller (E2377), light-emitting diode (LED) light kit (K0108), and self-leveling cup holder 
(K0108).