Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee is currently receiving appropriate care and 
is unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee's needs are being met in their current setting being provided by the health 
Plan. There is no therapeutic advantage to an LTACH transfer and their wounds are not sufficiently complex to 
meet criteria for LTACH admission. 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0481) rendered on 
April 26, 2023. 
 
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 the documentation submitted did not include documentation of the method of testing. 
 
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 G0481 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; 8-14 
drug class(es), including metabolite(s) if performed." 
 
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 laboratory report does not 
include documentation of the method of the testing. Therefore, this code cannot be verified. 
 
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 drug testing services (procedure code G0481) rendered on April 26, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 26, 
2023. 
 
You asked the Plan to waive the copayment for ambulance services. 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 $240 
copayment for ambulance services. 
 
You have been asked to pay a $240 copayment for ambulance services. 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 ambulance services 
provided on June 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig (A9282) and tax (S9999) purchased on March 14, 
2023. 
 
You asked the Plan to pay for the wig and tax. You say that the items should be covered. The Plan denied your 
request. The Plan says these are non-covered items. 
 Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. Medicare does not reimburse separately for sales 
tax.  
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282) and 
tax (S9999) purchased on March 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823). 
 
You asked the Plan to pre-approve a group 2 standard power wheelchair. You say that you believe the patient 
should receive the power wheelchair. The Plan denied your request. The Plan says based on Medicare 
guidelines, the power wheelchair requested does not meet the requirements for approval. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 group 2 standard power wheelchair. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the patient is 
functionally non-ambulatory and cannot use a cane or walker for mobility. The patient has had a knee 
arthroplasty with post-operative infection. They use a manual wheelchair for mobility. Our reviewer found that 
there is a lack of documentation regarding the patients level of function with daily activities as well as their 
ability to perform transfers. There is no documentation provided regarding the patient's graded motor strength 
and range of motion in the upper extremities. No mobility evaluation has been performed and there is no 
indication that the patient can safely transfer to and from the power wheelchair as well as use it. Our physician 
reviewer also found that there is no indication that the patient's home is accessible. 
 
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 group 2 standard power wheelchair have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a group 2 standard power wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge (D6240, D6750 x 2). 
 
You asked the Plan to pre-approve the dental service. You say that your tooth keeps falling out when you chew. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. The Plan's rules for coverage state to 
approve a bridge you must be missing only one upper front tooth or only two lower front teeth. The two lower 
front teeth must be next to each other. You also cannot be missing any of your back teeth.  
 
 
  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 dental service. Our reviewer says 
that the request is not medically necessary. Our physician reviewer found that based on the information in the 
x-ray, tooth number 18 has a very poor prognosis and is not a good candidate as one of the anchors of a bridge. 
Due to the amount of bone loss the foundation around the tooth is compromised. A bridge in this area would 
fail. You are also missing a tooth on the right lower jaw. A removable partial denture is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge (D6240, D6750 x 2).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel billed with codes 87653, 87500, 87641, 
87798, G0452, 87481 and 87651 for date of service August 8, 2023. 
 
You asked the Plan to pay for the laboratory panel. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this panel was not billed in 
accordance with Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that a test panel is a single test with multiple 
components and is characterized by a single unit of service (UOS =1). A panel cannot be unbundled and billed 
as individual components regardless of the fact that the test reports multiple individual pathogens and/or 
targets. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory panel have not been met. Specifically, the service at issue is a test panel which was 
unbundled and billed as individual components. Therefore, we decided that the Plan does not have to pay for 
the laboratory panel billed with codes 87653, 87500, 87641, 87798, G0452, 87481 and 87651 for date of 
service August 8, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the patient has been in your care for a prolonged 
period and has responded positively to the treatment you have prescribed. You also say that the patient cannot 
recover fully without the inpatient acute rehabilitation that has been recommended. The Plan denied your 
request. The Plan says based on the available information, admission to IRF is not reasonable and necessary.  
 
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 patient does not require the intensity of services provided at an IRF.  Specifically, 
the patient is not shown to require fifteen hours per week of rehabilitative services and regular physician 
evaluation.  The patients care needs can be met at a lower 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 pay for a heavy duty extra wide hospital bed (E0303). 
 
You asked the Plan to pay for the hospital bed. The Plan denied your request. The Plan says the coverage 
criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed (E0301, 
E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the 
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.  
 
We looked at the file and Medicare rules. The most recent submitted medical records do not show that you 
weigh between 350 and 600 pounds. Based on this information, we decided that Medicare rules for coverage of 
the hospital bed have not been met. Therefore, we decided that the Plan does not have to pay for a heavy duty 
extra wide hospital bed (E0303).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a group 1 standard POV. You say that the wheelchair you have is too small, 
and you cannot fit into it due to your height. The Plan denied your request. The Plan says the request does not 
meet the Medicare or health plan coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 group 1 standard POV. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found there is a lack of clinical 
documentation indicating your level of mobility and physical examination findings, specifically with regards to 
motor strength in the upper and lower extremities. There is no indication that you cannot use a cane or walker 
for assistance with mobility or propel a manual wheelchair. Our reviewer found that there is a lack of 
information as to whether you can safely operate the requested group 1 power mobility device and if your 
home is accessible. Our physician reviewer also found that while the documentation indicates that your current 
power wheelchair does not fit you due to your height and size, there is no documentation provided in terms of a 
mobility evaluation. 
 
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 group 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 1 standard power operated vehicle (POV) (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a walker provided on July 08, 2023. 
 
You asked the Plan to pay for a walker. You say that the supplies were medically necessary. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a walker provided on 
July 08, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee.  The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care 
and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is unstable for transfer and all needs are being met in the current hospital. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee needs continued treatments and care that can 
only be given in a current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time. 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's best chance for a quicker 
recovery and more favorable outcome will be with admission to the LTACH at this time where the enrollee can 
receive the individualized care plan and the aggressive treatment needed. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient acute care and is currently unstable for transfer to an 
LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is not yet stable for transfer and has all needs being met in the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 24, 2023. 
 
You asked the Plan to pay for the lab services. You say that fasfda The Plan denied your request. The Plan says 
the services cannot be verified. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the Clinical 
Laboratory Improvement Amendments (CLIA) number in the medical records does not match the CLIA 
number billed on the claim form. As such, the billed services cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab services provided on March 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this 
time because just underwent a complex abdominal surgery, and the pain is not under control to transfer to the 
next level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate at this time.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.