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 enrollee is a fall risk.  You say that IRF services 
would be the best chance to get back to baseline function.  The Plan denied your request. The Plan says the 
enrollee's condition does not meet the criteria for an IRF admission.  
 
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 that enrollee has no complex nursing or rehabilitation needs. 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 physical and/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 a ventilator for 3 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 3 months. 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 must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a ventilator for 3 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found a home ventilator is not 
medically necessary. An arterial blood gas done while stable as an outpatient on August 7, 2023, showed mild 
compensated carbon dioxide (CO2) retention. It appears the mild hypercarbia is predominantly caused by 
obesity hypoventilation syndrome. The appropriate treatment is continuous positive airway pressure (CPAP) or 
bilevel positive airway pressure (BiPAP). The medical records do not document that this has been tried and 
failed.  Medicare does not cover a home ventilator for the treatment of obesity hypoventilation syndrome, or 
when used at settings that can be provided with BiPAP. 
 
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 ventilator for 3 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 3 months (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (0315U) provided on January 10, 2023. 
 
You asked the Plan to pay for the laboratory services (0315U). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered as billed. 
 
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. 
 
Medicare rules also say that providers must report services correctly. Unless a specific exception is met, 
laboratory claims should be reported with the date of service the specimen was collected. 
 
We find that the reported date of service of January 10, 2023, is supported in the medical record. Specifically, 
the records indicate that the sample was obtained from storage on January 10, 2023, more than 30 days from 
the stored date. This means that an exception to the general rule for laboratory dates of service has been met. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have been 
met. Therefore, we decided that the Plan has to pay for the laboratory services (0315U) provided on January 
10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography cerebral perfusion analysis (CTP) 
provided on February 17, 2023. 
 
You asked the Plan to pay for the CTP. You say that the services were medically necessary. The Plan denied 
your request. The Plan says there is no documentation of acute ischemic stroke caused by unilateral large 
vessel occlusion. 
 
The Plan follows Medicare rules. Medicare rules say that they cover all services that are 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 pay for the CTP. Our reviewer says that the CTP not 
medically necessary. Our physician reviewer found the enrollee had a computerized tomography (CTA) scan 
on February 17, 2023, that revealed no evidence of infract or large vessel occlusion. For the CTP to be covered 
CMS rules state that large vessel occlusion amenable to interventional therapy be present in order for CTP to 
be considered necessary. The report shows no such large vessel lesion. The CTP is not reimbursable in this 
case. 
 
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 CTP have not been met. Therefore, we decided that the Plan does not have 
to pay for the computed tomography cerebral perfusion analysis (CTP) provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 95939, 95955, & 95938 billed for date of 
service January 10, 2023.  
You asked the Plan to pay for procedure code(s) 95939, 95955, & 95938. You say that this service was 
medically necessary. The Plan denied your request. The Plan says this code is included in the facility payment 
and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 95939, 95955, & 
95938. This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 95939, 
95955, & 95938. Based on this information, we decided that Medicare rules for coverage of procedure code 
95939, 95955, & 95938 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code(s) 95939, 95955, & 95938 billed for date of service January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #29. 
 
You asked the Plan to pre-approve the dental service. You say that the previous crown fell out and it is urgent 
to get a new crown. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
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 your benefit for the requested item or service was exhausted on the date of service of April 8, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth #29.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical records do not show that member has completed six weeks of 
provider-directed treatment that has taken place within the last three months. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the enrollee had plain x-rays on July 18, 2022, 
showing scoliosis and degenerative changes.  There has been no physical therapy (PT) yet.  Medical necessity 
for the requested MRI has not been established in the submitted records. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental service. You say that your previous denture was accidently 
broken, and you need a new denture. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
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 a complete lower denture (D5120) on February 16, 2022; therefore, your benefit for the 
requested item or service was exhausted on the date of service of February 16, 2022. Therefore, we decided 
that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 3, 2023, to May 
4, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you feel the self-administered medication 
should be covered by the Plan. The Plan denied your request. The Plan says the medication is not covered as a 
medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from May 3, 2023, to May 4, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs provided 
from May 3, 2023, to May 4, 2023. 
 
You asked the Plan to waive the cost for an ER visit and self-administered drugs. You say that you went to the 
emergency room and was admitted at the decision of your doctor. 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 $110 
copayment for emergency care.  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. 
 
You have been asked to pay $182.15 for an ER visit and self-administered drugs. This total includes a $110 
copayment for an ER visit and $72.15 for self-administered drugs. The ER visit falls within the emergency care 
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. 
Therefore, we decided that the Plan does not have to waive the cost for an ER visit and self-administered drugs 
provided from May 3, 2023, to May 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781), frames (V2020), lenses 
(V2783), anti-reflective coating (V2750) and deluxe lens feature (V2702) provided on April 11, 2023. 
 
You asked the Plan to pay for progressive lenses (V2781), frames (V2020), lenses (V2783), anti-reflective 
coating (V2750) and deluxe lens feature (V2702). You say that the final cost was way higher than presented to 
you. The Plan denied your request. The Plan says you are responsible for any amount over the $200 retail price. 
 
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 covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that you have a $200 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules also say that 
you are responsible for any amount over $200 retail price. Based on this information, we decided that the Plan's 
rules for coverage of progressive lenses (V2781), frames (V2020), lenses (V2783), anti-reflective coating 
(V2750) and deluxe lens feature (V2702) have not been met. The record shows the benefit was exhausted with 
this benefit. Therefore, we decided that the Plan does not have to pay for progressive lenses (V2781), frames 
(V2020), lenses (V2783), anti-reflective coating (V2750) and deluxe lens feature (V2702) provided on April 
11, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on February 23, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the scan billed 
is incorrect and the cost share applied should be $0. 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 $220 
copayment for outpatient hospital services. 
 
You have been asked to pay a $220 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient hospital 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 you owe is $89.44, which is less than the standard copayment for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography 
(CT) scan provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a hearing aid (V5298) provided on January 2, 2023. 
 
You asked the Plan to reimburse for a hearing aid (V5298). You say that you are covered up to $5,000 with 
your Plan. You also say that the hearing aids are covered when purchasing from the rendering provider. The 
Plan denied your request. The Plan says their records indicate the maximum benefit has been exhausted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays up to 
$5,000 for hearing aids only once every three years.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules also say that the Plan pays up to a $5,000 allowance 
for hearing aids (combined for both ears) every 3 years. The record shows that this benefit was exhausted on 
May 11, 2021. Based on this information, we decided that the Plan's rules for coverage of a hearing aid 
(V5298) have not been met. Therefore, we decided that the Plan does not have to reimburse for a hearing aid 
(V5298) provided on January 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show enrollment in a clinical trial. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that any potential benefit or detriment of proton therapy over standard IMRT is an investigational 
question (being pursued in randomized studies- i.e. for intermediate to low risk prostate cancer). To date, there 
are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on 
October 26, 2022. 
 
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) 99223 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 provided records in this case 
do not contain a note documenting a chief complaint, an extended history of present illness, a review of all 
additional body systems and a complete past, family and social history for date of service October 26, 2022. 
Additionally, the records in this case do not contain a note documenting a general multisystem examination or 
a complete examination of a single organ system for this date of service. The provided records in this case do 
not contain a note documenting 2 out of 3 of an extensive number of diagnoses or management options, an 
extensive amount and complexity of data reviewed and high risk of complication. The records do not support a 
comprehensive history, comprehensive exam, or medical decision making of high complexity. 
 
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 initial hospital care (procedure code 99223) rendered on October 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper 
extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that you have had shoulder problems but only the elbow 
MRI has been done so far. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found during last encounter of July 14, 2023, no 
mention of right shoulder issues was noted in the history or physical exam. No x-rays of right shoulder 
documented. Physical therapy (PT) has been prescribed presumably for your right elbow pain but also could 
include right shoulder issues. No other conservative management for your right shoulder issues have been 
noted. 
 
 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint.