Persius/hicric huggingface dataset:
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 medically necessary for the enrollee 
to receive the care needed to ensure a safe return home. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs for Group 3 power wheelchair. 
 
You asked the Plan to pre-approve repairs for Group 3 power wheelchair. The Plan denied your request. The 
Plan says the enrollee does not have a diagnosis for which a Group 3 power wheelchair is reasonable and 
necessary. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Since the enrollee does not meet the coverage criteria for a Group 3 
power wheelchair, repairs to an existing Group 3 power wheelchair cannot be covered. Therefore, we decided 
that the Plan does not have to pre-approve repairs for Group 3 power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services billed with Patient-Driven 
Grouping Model (PDGM) 4EB11 for date of service May 27, 2021, to June 25, 2021. 
 
You asked the Plan to pay for the home health services billed with Patient-Driven Grouping Model (PDGM) 
4EB11. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the 
services are not payable as billed. 
 
The Plan follows Medicare rules. Medicare rules say that both the claims data and OASIS data are used to 
determine the HIPPS codes. 
 
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 home health services billed with Patient-
Driven Grouping Model (PDGM) 4EB11. Our reviewer says that the documentation does not support the 
services billed. Our physician reviewer found no OASIS form was provided for the services at issue. Therefore, 
the services are not payable as billed. 
 
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 home health services billed with Patient-Driven Grouping Model (PDGM) 
4EB11 have not been met. Therefore, we decided that the Plan does not have to pay for the home health 
services billed with Patient-Driven Grouping Model (PDGM) 4EB11 for date of service May 27, 2021, to June 
25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of tunneled central venous catheter, without 
subcutaneous port or pump (36589) provided on June 02, 2023. 
 
You asked the Plan to pay for removal of tunneled central venous catheter, without subcutaneous port or pump 
(36589). You say that the service was medically necessary The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for removal of tunneled 
central venous catheter, without subcutaneous port or pump (36589) provided on June 02, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive audiometry threshold evaluation and speech 
recognition (92557) provided on October 17, 2023, by an out-of-network (OON) provider.  
 You asked the Plan to pay for a comprehensive audiometry threshold evaluation and speech recognition with 
an out-of-network provider. You say that the service was authorized. The Plan denied your request. The Plan 
says the service by the out-of-network provider was not authorized. 
 
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 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. While 
the provider supplied evidence of authorization number ending in 5519 having been issued by the Plan, the 
documentation shows that this authorization applied to codes 99204 and 99214. There is no evidence that prior 
authorization was issued for code 92557 with an OON provider. Therefore, we decided that the Plan does not 
have to pay for a comprehensive audiometry threshold evaluation and speech recognition (92557) provided on 
October 17, 2023, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography scan provided on 
March 29, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography scan. You say that this service should 
be fully covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $195 copayment for a computed tomography scan. This item/service falls within 
the outpatient diagnostic tests and therapeutic services and supplies 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. However, since the allowed amount is less than the 
standard copayment, you only owe $143.19. Therefore, we decided that the Plan does not have to waive the 
copayment for a computed tomography scan provided on March 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on June 24, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the lab services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The genetic testing in this case was billed with multiple codes and 
not one code as required by Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
panel provided on June 24, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy service provided on 
August 07, 2023, to August 21, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy service. You say that you were unaware 
of the copayments. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $25 copayment for each physical therapy service. This item/service falls within 
the outpatient rehabilitation 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 total amount you owe is $125 ($25 copayment x 5 visits = $125). 
Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy service 
provided on August 07, 2023, to August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the principle care management services provided on August 
04, 2023. 
 
You asked the Plan to pay for the principle care management services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the principle care 
management services provided on August 04, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a regadenoson injection provided on 
September 14, 2023. 
 
You asked the Plan to waive the coinsurance for a regadenoson injection. You say that you were unaware of 
the cost of the injection. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a regadenoson injection. This item/service falls within the 
Medicare Part B prescription drugs 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 total amount you owe is $49.03 ($245.13 allowed amount x 20% = $49.03). 
Therefore, we decided that the Plan does not have to waive the coinsurance for a regadenoson injection 
provided on September 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) and a portable oxygen 
concentrator (E1392) provided on June 17, 2023. 
 
You asked the Plan to pay for oxygen equipment. You say that you disagree with the denial and have submitted 
medical records for review and reprocessing of the claim.  The Plan denied your request. The Plan says two of 
the billed diagnosis codes cannot be reported together. 
 The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. One such guideline indicates that certain diagnosis codes have an Excludes1 note which lists other 
diagnosis codes with which they cannot be reported.  
 
In this case, we have confirmed that J44.9 has an Excludes1 note in relation to J47.9. This means that the two 
diagnosis codes cannot be reported together. Based on this information, we decided that the Medicare billing 
rules for oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay for an 
oxygen concentrator (E1390) and a portable oxygen concentrator (E1392) provided on June 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a magnetic resonance imaging (MRI) scan (73721) provided 
on July 13, 2022. 
 
You asked the Plan to pay for an MRI scan. You say that the service at issue was a necessity for your care. The 
Plan denied your request. The Plan says the service at issue is ineligible for coverage when ordered by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue was ordered by a chiropractor. The service is not manual 
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a magnetic resonance 
imaging (MRI) scan (73721) provided on July 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low-dose radiation therapy. 
 
You asked the Plan to pre-approve low-dose radiation therapy. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational 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 low-dose radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the case record describes conventional treatments not working well but 
explicitly states that the enrollee has not tried steroid injections, which would be the accepted standard of care 
at this point. The enrollee has not exhausted standard treatment options.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of low-dose radiation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve low-dose radiation therapy.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that this is considered 
experimental/investigational at this time.  
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found genicular artery embolization is fairly commonplace in competent and hands and 
should be approved as a minimally invasive treatment for chronic knee pain of advanced osteoarthritis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have been met. Therefore, we decided that the 
Plan has to pre-approve genicular artery embolization.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), the 2D 
photographic images (D0350), and the oral hygiene instructions provided on September 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan's database needs to be corrected and 
you plan on switching dentist again. The Plan denied your request. The Plan says your benefit for the 
panoramic radiographic image and the 2D photographic images has already been exhausted. Also, the oral 
hygiene instructions are not covered by the Plan. 
 
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, certain limitations apply. The record 
shows the Plan paid for the intraoral complete series of radiographic images (D0210) on March 3, 2023; 
therefore, your benefit for the panoramic radiographic image (D0330) was exhausted on the date of service of 
March 03, 2023. The records shows the Plan paid for a 2D photographic image (D0350) on September 7, 2023; 
therefore, your benefit for the 2D photographic images (D0350) was exhausted on the date of service of 
September 7, 2023. The oral hygiene instructions are not covered under the Plan's dental benefit. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330), the 2D photographic 
images (D0350), and the oral hygiene instructions provided on September 7, 2023.
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 enrollee requires an IRF level of care. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
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, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the computed tomography (CT scan) of the head or brain and the 
cervical spine billed with codes 70450 and 72125 provided on July 18, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the services were billed correctly and should be paid. 
The Plan denied your request. The Plan says that codes 70450 and 72125 were billed by another provider for 
the same date of service. The Plan says that the services were billed on another claim and was paid. 
 
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. We find that the Plan did not provide any evidence to prove that this service was 
previously billed and paid. Therefore, we decided that the Plan has the computed tomography (CT scan) of the 
head or brain and the cervical spine billed with codes 70450 and 72125 provided on July 18, 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.