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 you want to go to rehab to be able to then go home 
for in-home care. The Plan denied your request. The Plan says the complexity of the enrollee's nursing, medical 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitative care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 21, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for a take-home supply of methadone; up to 7 additional day supply 
provided on January 9, 2023. 
 
You asked the Plan to pay for a take-home supply of methadone; up to 7 additional day supply. You say that 
you have been enrolled in the Medicare program to provide OTP services since January 1, 2020. The Plan 
denied your request. The Plan says that the claim for these drugs was billed by the physician, not the opioid 
treatment program (OTP) facility. 
 
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 rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for a take-home supply of 
methadone; up to 7 additional day supply provided on January 9, 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 Electrocardiogram, routine ECG with at least 12 leads; 
interpretation and report only (93010) provided on December 12, 2022. 
 
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records submitted do not support procedure code 93010 
 
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 93010 is an electrocardiogram, routine ECG with at least 
12 leads; interpretation and report only. 
 
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 electrocardiogram. Our reviewer says that the 
documentation does not support procedure code 93010. Our reviewer found that there is no documentation of a professional interpretation performed on this date. This also does not support use of modifier 59 as a separately 
identifiable procedure. 
 
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 electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 
(93010) provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electric seat lift mechanism (E0627) and non-covered 
service (A9270) provided on December 23, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an electric seat lift mechanism and non-covered service. You say that this is the 
only supplier in your immediate area, and you were unaware that that they were not a Medicare accredited 
supplier. The Plan denied your request. The Plan says these items are not when they are not provided by a 
participating provider. 
 
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. 
Therefore, we decided that the Plan does not have to pay for an electric seat lift mechanism (E0627) and non-
covered service (A9270) provided on December 23, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia for intraoral procedures, including biopsy; not otherwise 
specified (code 00170) provided on February 16, 2022. 
 
You asked the Plan to pay for anesthesia for intraoral procedures, including biopsy; not otherwise specified. 
You say that the services were medically necessary. The Plan denied your request. The Plan says that Medicare 
dental coverage and Medicare does not cover anesthesia for intraoral procedures (00170) under the member's 
medical dental benefit plan when there is not a primary service facility claim that processed towards the 
Medicare dental benefit. 
 
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. Specifically, the Plan has not provided a Plan dental benefit rule to substantiate 
their denial. Therefore, we decided that the Plan has to pay for anesthesia for intraoral procedures, including 
biopsy; not otherwise specified (code 00170) provided on February 16, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that these services were authorized by the Plan. 
The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 28, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special stain including interpretation and report coded 
88312 for date of service February 23, 2023. 
 
You asked the Plan to pay for the special stain including interpretation and report. 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 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 88312 is special stain including interpretation and report; 
Group I for microorganisms (eg, acid fast, methenamine silver). 
 
We find that CPT code 88312 is not supported in the medical record. Specifically, this service was billed with 
modifier 76. This modifier is inappropriate to be appended to laboratory service codes. Based on this 
information, we decided that Medicare rules for coverage of the special stain including interpretation and report 
have not been met. Therefore, we decided that the Plan does not have to pay for the special stain including 
interpretation and report coded 88312 for date of service February 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 29, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 30, 2022. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says this service was 
provided by a provider that chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided on August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes A6212 and A6196 for date of service 
November 14, 2022. 
 
You asked the Plan to pay for procedure codes A6212 and A6196. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are not separately payable. 
 
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 codes A6212 and A6196 are not payable as billed. Specifically, codes A6212 and A6196 
have a status code indicator of "P". This means no separate payment can be made for these items. Based on this 
information, we decided that Medicare rules for coverage of procedure codes A6212 and A6196 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes A6212 and A6196 for date 
of service November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for charges associated with the Shingles vaccine provided on 
August 2, 2022. 
 
You asked the Plan to pay for the Shingles vaccine. You say that you have called and no one will give you the 
address to file a Part D claim. The Plan denied your request. The Plan says charges related to the Shingles 
vaccine are not covered under the patient's medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles 
vaccine. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for charges associated with the Shingles 
vaccine provided on August 2, 2022.  
 Benefits for the Shingles vaccine 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for acute inpatient hospital services rendered from February 17, 2021, to 
February 23, 2023. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the medical records do not show medical necessity for this stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for acute inpatient hospital services rendered from February 17, 2021, to February 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204), eye refraction (92015), 
gonioscopy (92020), and scanning computerized ophthalmic diagnostic imaging (92133) provided on January 
13, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit, eye refraction, gonioscopy, and diagnostic imaging. 
You say that these were necessary procedures that you needed at the moment, and you could not wait. The Plan 
denied your request. The Plan says an authorization was not obtained prior to the services being rendered and 
the provider is not participating with your plan. The Plan also says the services rendered were not Plan 
Directed Care. 
 
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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99204), eye refraction 
(92015), gonioscopy (92020), and scanning computerized ophthalmic diagnostic imaging (92133) provided on 
January 13, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the polycarbonate lenses, the anti-reflective coating, and the 
miscellaneous vision item provided on December 22, 2022.  
You asked the Plan to pay for the polycarbonate lenses, the anti-reflective coating, and the miscellaneous 
vision item. You say that the provider was supposed to be in-network. You say you were not told that the 
polycarbonate lenses were not covered. The Plan denied your request. The Plan says the items are not covered 
benefits. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. Specifically, the items are not covered benefits. Based on this 
information, we decided that the Plan's rules for coverage of the polycarbonate lenses, the anti-reflective 
coating, and the miscellaneous vision item have not been met. Therefore, we decided that the Plan does not 
have to pay for the polycarbonate lenses, the anti-reflective coating, and the miscellaneous vision item provided 
on December 22, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the fundus photography (92250) provided on February 15, 2023. 
 
You asked the Plan to pay for the fundus photography. You say that the doctor did not explain to you that this 
service is not covered by your plan. The Plan denied your request. The Plan says that this service is not covered 
by the Plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the Plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the fundus photography by a contract provider. The file does not show that the Plan 
provided notice that the fundus photography would not be covered. Under Medicare rules, this means the 
fundus photography is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
fundus photography (92250) provided on February 15, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has preferred drugs that you must try first.  
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that the plan requires a 
trial of Aranesp or Procrit before they will approve the requested drug. In this case the enrollee has not tried 
and failed the required drugs. There is no documentation provided indicating that the plans required drugs 
would likely be less effective and/or likely have adverse effects for 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.