Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy (PT). 
 You asked the Plan to pre-approve home health services. You say that it is felt that additional home health 
services are required.  The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found twenty-six 
additional units of G0159 home health physical therapy maintenance program, 23 units of G0151 physical 
therapy, and 6 units of G0153 speech therapy have been requested. At issue in this case is whether the 
additional therapy is eligible for coverage under Medicare guidelines.  
 
The patient is dependent for mobility and transfers and has contractures of the upper and lower extremities. 
After the physical and speech therapy treatments already provided (since 08/26/2022) records do not support 
that the complexity of the patients conditions are such that the skills of a professional therapist are required to 
achieve further improvement in the enrollee's symptoms or functional status. Further utilization of the home 
exercise program and caregiver support appear appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy (PT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the NASH FibroSure test (0003M). 
 
You asked the Plan to pay for the NASH FibroSure test. You say that please see the attached lab results and 
reprocess CPT code 00003 for payment.  The Plan denied your request. The Plan says the clinical value and 
effectiveness of the NASH FibroSure test in the setting of fatty liver have not been demonstrated in the peer-
reviewed literature.  
 
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 NASH FibroSure test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found FibroSure is not the standard of care by national clinical guidelines and is not 
medically appropriate. 
 
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 NASH FibroSure test have not been met. Therefore, we decided that the 
Plan does not have to pay for the NASH FibroSure test (0003M).
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care received on January 20, 2023, to 
January 23, 2023. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary. The Plan denied 
your request. The Plan says that Original Medicare is responsible for the services. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan's denial on the basis of the enrollee electing hospice on January 20, 
2023, is incorrect because the enrollee was not in hospice at that time, and the plan did not offer another reason 
for denying the claim. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care 
received on January 20, 2023, to January 23, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bystolic. 
 
You asked the Plan to pre-approve the medication. 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 pre-approve Bystolic.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service provided on January 
06, 2023. 
 
You asked the Plan to waive the copayment for the ambulance service. You say that you cannot afford this 
copayment. 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 $325 
copayment for ambulance services. 
 
You have been asked to pay a $325 copayment for the ambulance service. This item/service falls within the 
ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance 
service provided on January 06, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
January 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that you never received material saying the x-ray was 
limited to 1 in 36 months. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. Also, Medicare rules state only a completely new enrollee receives an EOC 
and the Plan is not required to mail hard copies as long as the enrollee can access electronically. 
 
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 August 17, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on October 19, 2021, to 
October 27, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim is billed correctly and should be paid. The Plan denied your request. The Plan says documentation does 
not support the billed code. 
 
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 provided with secondary diagnosis code A41.9, described as 
sepsis, unspecified organism. 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 documentation does not support the billed 
code. Our physician reviewer found that the enrollee is an 88-year-old female who presented to the hospital 
with weakness and decreased urination. Urinary tract infection was diagnosed based on urinalysis with positive 
leukocyte esterase and treated with antibiotics and fluids. Workup also revealed the enrollee was afebrile, 
without leukocytosis, without thrombocytopenia, with normal bilirubin, with normal blood pressure and urinary 
output following fluids, with Glasgow Coma Scale (GCS) 14-15 with baseline dementia, normal oxygenation, 
and in no distress. The records did not describe the enrollee with a severe infection and did not describe a 
dysregulated response to infection with life-threatening organ failure. Sepsis 3 criteria was not met. Therefore, 
the code, A41.9 (sepsis) is not supported for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on October 19, 2021, to October 27, 2021, at the Diagnosis Related 
Group (DRG) originally billed.
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 on two expensive intravenous 
antibiotics and the skilled nursing facility will not be able to afford to cover the cost. You say the infection will 
spread throughout the enrollee's blood stream and possibly cause sepsis that may result in death. 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99499) with an ophthalmologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that there is concern that you may have macular 
degeneration. You would like to be seen immediately. The Plan denied your request. The Plan says you do not 
have OON benefits. You must receive your care from a network provider. There are in network physicians who 
are able to treat this diagnosis. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99499) with an ophthalmologist to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rehabilitation services billed with codes 97110, 97116, 
97140, and 97530 provided from January 7, 2022, to January 12, 2022. 
 
You asked the Plan to pay for the rehabilitation services . You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the claim was submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 
 
 
 
 The record shows that a claim for the rehabilitation services  was not filed until April 27, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the rehabilitation services billed with codes 97110, 97116, 
97140, and 97530 provided from January 7, 2022, to January 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a emergency room visit provided on March 
22, 2023, to March 24, 2023. 
 
You asked the Plan to waive the copayment for a emergency room visit. You say that you disagree with the 
copayment. 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 $50 
copayment for emergency care. 
 
You have been asked to pay a $50 copayment for a emergency room visit. This item/service 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 copayment for a emergency room visit 
provided on March 22, 2023, to March 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram provided on October 03, 2022. 
 
You asked the Plan to pay for an electrocardiogram. You say that you are requesting reconsideration of the 
denied claim. 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 an electrocardiogram 
provided on October 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for E0781 billed for date of service December 16, 2022. 
 You asked the Plan to pay for the billed services. You say that the unit was prescribed due to medical necessity. 
The Plan denied your request. The Plan says an appropriate modifier was not billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code E0781 is under the capped rental (RR) payment class. A modifier has not been 
appended to the code to indicate the equipment is a rental. 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 E0781 billed for date of service December 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (01924) provided on January 24, 
2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that payment can be made under the fee schedule for 
anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. Payment is 
determined based on the base unit of the anesthesia procedure with the highest base unit value and time units 
based on the actual anesthesia time of the multiple procedures.  
 
We looked at the file and Medicare rules. In this case, the two anesthesia services were billed on the same date 
of service. Code 01270 was already processed and paid by the Plan on February 25, 2023. As code 01270 has 
the highest base unit value, separate payment cannot be made for code 01924. 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 anesthesia services (01924) provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an OON 
provider.  
 
You asked the Plan to pre-approve the acupuncture services. You say that there are no in-network providers. 
The Plan denied your request. The Plan says there are in-network providers in your area. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the acupuncture services to be provided by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the AlloSure Kidney test (81479) provided September 2, 2021, to 
February 7, 2022. 
 
You asked the Plan to pay for the AlloSure Kidney test. You say that the AlloSure Kidney test was medically 
necessary and is used in clinical practice to aid in the management of the enrollee. The Plan denied your 
request. The Plan says that the requested service is not medically necessary. 
 
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 pay for the AlloSure Kidney test. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found AlloSure is a Medicare approved test for transplant rejection when used over 2 weeks post-
transplant. It is an important test because it can detect rejection without biopsy (which is an invasive procedure) 
and can detect early and hopefully avoid loss of viable renal tissue that can be lost with an episode of rejection. 
The test is indicated in this case and was used appropriately. 
 
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 AlloSure Kidney test have been met. Therefore, we decided that the Plan 
has to pay for the AlloSure Kidney test (81479) provided September 2, 2021, to February 7, 2022.  
 
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 insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (22869). 
 
You asked the Plan to pre-approve a Vertiflex device placement. You say that you cannot do normal cleaning, 
cooking or even standing long. The Vertiflex procedure will help you function normally, or you will end up in 
a wheelchair. The Plan denied your request. The Plan says unproven and not medically necessary procedures 
are not covered by Medicare. 
 
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 a Vertiflex device placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Vertiflex device is experimental and investigational. There is more 
research needed due to insufficient evidence of efficacy. 
 
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 Vertiflex device placement have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device, without open decompression or fusion, including image guidance when performed, lumbar; single level 
(22869).