Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an air immersion therapy mattress and semi-electric 
hospital bed (E1399, E0261). 
 
You asked the Plan to pre-approve an air immersion therapy mattress and semi-electric hospital bed. 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. 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 an air immersion therapy mattress and 
semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found Medicare provides an air fluidized 
mattress for persons with chronic stage IV ulcers. The benefit of air immersion vs air fluidized mattress had not 
been established.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an air immersion therapy mattress and semi-electric hospital bed have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an air immersion therapy mattress and 
semi-electric hospital bed (E1399, E0261).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breath hydrogen/methane test. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that lactulose breath hydrogen for diagnosing small bowel 
bacterial overgrowth and measuring small bowel transit time is excluded from coverage. 
 
We looked at the file and Medicare rules. The services at issue are breath hydrogen testing. This testing is not 
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a breath 
hydrogen/methane test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 3, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that this is supported in the records. The Plan denied 
your request. The Plan says enrollees must receive their care from a network 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 
items/services 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 lab services provided on May 3, 2023, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter (99239) provided January 20, 2023. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
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 service. Our reviewer found CPT code 99239 remains not supported. The medical records submitted do not support a hospital discharge day management more than 30 
minutes was performed. A documented duration of time of more than 30 minutes is required to support this 
code. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the hospital inpatient or observation discharge day management; more than 30 minutes on the 
date of the encounter (99239) provided January 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug test, 15-21 drug class(es) (G0482) provided 
February 20, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is not supported in the medical record. Code G0482 (1 Unit) remains not 
supported. The submitted medical records do not contain sufficient detail to support the billed charges. The 
medical records submitted do not include an order that specifically list what test(s) are to be performed. Based 
on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug test, 15-21 drug class(es) (G0482) 
provided February 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 20, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a tertiary hematologist/oncologist.  
 
You asked the Plan to pre-approve a consultation with a tertiary hematologist/oncologist. You say that you live 
in Laguna Woods and your husband is in a wheelchair. You say that it's too difficult for you to go to the 
network providers. You say that your cancer can get worse with the high readings you've been getting. You say 
that you want to avoid chemotherapy. The Plan denied your request. The Plan says the notes received do not 
show that the member needs a higher level of care.  
 
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 consultation with a tertiary 
hematologist/oncologist. Our reviewer says that a consultation with a tertiary hematologist/oncologist is not 
considered medically reasonable and necessary in this case. Our physician reviewer found you have right breast cancer and opted for breast conserving therapy. The Plan has non-tertiary care available for medical oncology. 
There is nothing unique about your condition that would necessitate tertiary care. There is no mention of a 
clinical trial.  
 
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 consultation with a tertiary hematologist/oncologist have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a consultation with a tertiary 
hematologist/oncologist.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound guidance for vascular access requiring 
ultrasound evaluation of potential access sites (76937-26) provided March 6, 2023. 
 
You asked the Plan to pay for the ultrasound guidance. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 76937 is ultrasound guidance for vascular access 
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent 
realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List 
separately in addition to code for primary procedure). 
 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 ultrasound guidance. Our reviewer found CPT code 
76937-26 (1 Unit) was not supported. This CPT code represents an ultrasound guidance for vascular access. 
The code requires ultrasound evaluation of potential access sites; documentation of selected vessel patency; 
concurrent real-time ultrasound visualization of vascular needle entry; and permanent recording and reporting. 
In this case, the records did not include documentation of selected vessel patency. The review has determined 
that the documentation did not support procedure code 76937-26 provided March 6, 2023. 
 
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 ultrasound guidance have not been met. Therefore, we decided that the Plan 
does not have to pay for the ultrasound guidance for vascular access requiring ultrasound evaluation of 
potential access sites (76937-26) provided March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye examination provided on 
March 23, 2023. 
 
You asked the Plan to waive the copayment for the medical eye examination. You say that this was part of a 
routine eye examination and there should be a $0 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 $15 
copayment for each Medicare-covered exam.  
 
 You have been asked to pay a $15 copayment for the medical eye examination. The medical eye examination 
falls within the vision care benefit category. The records show diagnoses of dry eye and drusen, which makes 
the eye examination medical in nature. 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 medical 
eye examination provided on March 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee requires therapy in a SNF after their hip 
surgery. The Plan denied your request. The Plan says a SNF admission is not medically necessary.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF services is medically necessary. The Plan 
denied your request. The Plan says that you no longer had skilled nursing facility needs.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you did not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you have been in and out of the hospital three times 
within the last three months because the infection has gotten worse. The Plan denied your request. The Plan 
says based on Medicare guidelines, the SNF services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the brain to be provided by OON provider.  
 
You asked the Plan to pre-approve an MRI of the brain. You say that the requested imaging is medically 
necessary. The Plan denied your request. The Plan says the enrollee must receive your care from a network 
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 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 MRI of the brain to be provided by OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic services provided February 7, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. Review of the file shows 
that the place of service 11 was billed; however, the documentation received does not support the services 
performed in an office or other outpatient setting, but rather in a mobile setting at a skilled nursing facility 
(SNF). There is a more appropriate place of service code (POS 15). Therefore, we decided that the Plan does 
not have to pay for the radiologic services provided February 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office and radiologic services provided March 13, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. Review of the file shows 
that the place of service 11 was billed; however, the documentation received does not support the services 
performed in an office or other outpatient setting, but rather in a mobile setting at a skilled nursing facility 
(SNF). There is a more appropriate place of service code (POS 15). Therefore, we decided that the Plan does 
not have to pay for the office and radiologic services provided March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiologic services provided March 29, 2023. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the medical services have not been met. Review of the file shows 
that the place of service 11 was billed; however, the documentation received does not support the services 
performed in an office or other outpatient setting, but rather in a mobile setting at a skilled nursing facility 
(SNF). There is a more appropriate place of service code (POS 15). Therefore, we decided that the Plan does 
not have to pay for the radiologic services provided March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse more for a monaural hearing aid (V5050) provided on 
May 8, 2023. 
 
You asked the Plan to reimburse more for a monaural hearing aid (V5050). You say that the reimbursement for 
the $2,000 benefit for which you were only reimbursed $1,600. You also say you are requesting the amount of 
$400, which would be the rest. 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 out-of-network covered hearing services.  
 
 You have been asked to pay $400 in coinsurance, which is 20% of the allowed amount for a monaural hearing 
aid ($2,000 x 20% = $400). This item/service falls within the out-of-network covered hearing 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 reimburse more for a monaural hearing aid (V5050) provided on May 8, 
2023.