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

 
We decided that the Plan does not have to pay for the home health services provided on January 4, 2023. 
 
You asked the Plan to pay for home health services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were 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 pay for home health services. Our reviewer says that 
the services were not medically reasonable and necessary. Our physician reviewer found the records do not 
support that the enrollee required additional skilled nursing or skilled rehabilitation services to effectively 
provide treatment, care, and/or services in order to improve her condition, perform a maintenance program to 
maintain the members condition and/or prevent deterioration. The enrollee has been medically stable without 
any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services 
were not medically necessary. 
 
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 pay for the home health services provided on January 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests (82306, 82607, 82746, 83036, 84436, 84479 
and 84480) provided on March 29, 2022. 
 
You asked the Plan to pay for laboratory tests. You say that these services were medically necessary and are 
supported in the medical record. The Plan denied your request. The Plan says these services were provided for 
screening purposes and were not performed as medically necessary diagnostic services. In addition, the 
payment for codes 84479, 84480 and 84436 is bundled into the payment for other services billed on this claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules also say that providers must report 
services correctly. Providers must report services with the appropriate CPT code. 
 
The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these 
tests solely for screening purposes. In addition, we have confirmed that codes 84479, 84480 and 84436 are 
column II codes to column I codes 84439, 84481 and 84439, respectively. Each of these code pairs has a 
modifier indicator of 0. The column II codes are therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met for these services. Therefore, we decided that the Plan does not have to pay 
for laboratory tests (82306, 82607, 82746, 83036, 84436, 84479 and 84480) provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 14, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on May 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a headrest cover (K0108) and an electronic connection 
(E2311). 
 You asked the Plan to pre-approve a headrest cover and an electronic connection. The Plan denied your 
request. The Plan says the headrest cover does not serve a medical purpose and cannot be covered. The Plan 
also says that there is not a medical need to control these power options through the joystick. 
 
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 electronic connection. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has adequate strength in upper extremities to manage standard power 
drives. Our reviewer also found that this request exceeds what is necessary to meet enrollee's needs. 
 
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 headrest cover and an electronic connection have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a headrest cover (K0108) and an electronic connection 
(E2311).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant Reveal (81479) provided on September 26, 2022. 
 
You asked the Plan to pay for Guardant Reveal. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says this test has not met Medicare criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guardant Reveal have not been met. Therefore, we decided that the Plan does 
not have to pay for Guardant Reveal (81479) provided on September 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99233 billed for date of service September 
27, 2022.  
 
You asked the Plan to pay for procedure code 99233. The Plan denied your request. The Plan says payment for 
code 99233 is bundled into payment for code 99223. 
 
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, we have confirmed that code 99233 
is a column II code to column I code 99223 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 99233 billed for date of service September 27, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
January 9, 2023.  
 You asked the Plan to pay for the ED services. You say that you feel that the law requires the Plan to make 
payment according to reasonable costs and that you cannot accept Medicare fee schedule payment.  The Plan 
denied your request. The Plan says Medicare plans are not allowed to make payment for freestanding ED 
services unless the provider has enrolled as a temporary hospital under the COVID waiver rules. 
 
The Plan must follow Medicare rules. Medicare rules say that freestanding EDs are not payable by Medicare, 
aside from providers who enroll as temporary hospitals.  
 
We looked at the file and Medicare rules. Medicare records and the appeal request confirm that this provider is 
not enrolled as a Medicare temporary hospital. Based on this information, we decided that Medicare rules for 
coverage of the ED services have not been met. Therefore, we decided that the Plan does not have to pay for 
the emergency department (ED) services provided on January 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator.  
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume-assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rotational unit (K1022), fluid swing and stance phase 
control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), and microprocessor control 
feature (L5856). 
 
You asked the Plan to pre-approve a rotational unit, fluid swing and stance phase control, stance flexion 
feature, fluid stance extension, and microprocessor control feature. You say that there are notes from the 
ordering physician explaining the need for the advanced knee and foot feature. The Plan denied your request. 
The Plan says while it is documented that the enrollee has K3 potential, there is no reason why a 
microprocessor knee is medically necessary for the enrollee. The Plan also says a rotational unit does not serve 
a medical purpose. 
 
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 rotational unit, fluid swing and stance 
phase control, stance flexion feature, fluid stance extension, and microprocessor control feature. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the physician documentation indicates the enrollee has K3 potential however the 
documentation from the physician does not support that the enrollee's activities need a microprocessor knee 
over a mechanical knee. The physician documentation also does not support the need for a K1022 rotational 
unit. Our reviewer also found that the requested items-rotational unit (K1022), fluid swing and stance phase 
control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), and microprocessor control 
feature (L5856) exceed the enrollee's medical needs and are not medically necessary. 
 
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 rotational unit, fluid swing and stance phase control, stance flexion feature, 
fluid stance extension, and microprocessor control feature have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a rotational unit (K1022), fluid swing and stance phase control (L5828), 
stance flexion feature (L5845), fluid stance extension (L5848), and microprocessor control feature (L5856).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 would benefit from rehab to return to 
prior level of function. The Plan denied your request. The Plan says that the IRF services you are requesting 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the complexity of the enrollee's documented nursing, medical and rehabilitation needs would be expected 
to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It would be 
expected that the enrollee would participate and significantly benefit from an intensive rehabilitation program. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge management services provided on November 
7, 2022.  
 
You asked the Plan to pay for the discharge services. You say that the services were medically necessary and 
should be reimbursed. The Plan denied your request. The Plan says the date of service in this case is after the 
enrollee's date of death. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the discharge services have been met. 
The documentation does not support the billed date of service. The enrollee's date of death is listed in Medicare 
records as November 6, 2022. The medical records support the services were performed on November 6, 2022, 
not November 7, 2022, as reported on the claim. Therefore, we decided that the Plan does not have to pay for 
the discharge management services provided on November 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation to be provided by an out-
of-network tertiary care provider, City of Hope. 
 
You asked the Plan to pre-approve the tertiary care services. You say that it takes too long to get an 
appointment within the Plan and timing is very important for you given your diagnosis. The Plan denied your 
request. The Plan says appropriate care is available in-Plan in various discipline of medical oncology, radiation 
oncology, interventional radiology 
and also in hepatology; therefore, your request for an out-of-Plan referral is not medically necessary at this 
time. 
 
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 provider at issue in this case is not a network provider with the Plan. 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 tertiary care services. Our physician reviewer found the Plan has 
demonstrated that a second medical oncology is available in-network. There is nothing unusual about your 
diagnosis that makes a referral to a tertiary care provider necessary. The service is not reasonable or medically 
necessary.  
 
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 tertiary care services have not been met.  
 
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 the tertiary care services. Therefore, we decided that 
the Plan does not have to pre-approve a second opinion consultation to be provided by an out-of-network 
tertiary care provider, City of Hope.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C intravenous immune globulin (IVIG). 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that IVIG is covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted medical records 
document a "chronic axonal sensorimotor peripheral polyneuropathy" on nerve conduction/electromyography 
without clear documentation of the presence of demyelination. The records do not include objective measures 
of improvement in the enrollee's condition with prior immunoglobulin administration do not clearly show that 
the enrollee's symptoms are not due to another etiology such as alcohol-related polyneuropathy. The criteria for 
coverage are not met and the IVIG is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C intravenous immune globulin (IVIG).
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 require daily attention by physician to treat 
impaired mobility regain strength and endurance and safety education to return home with strategies to live 
with new amputation. The Plan denied your request. The Plan says your records do not show that you have 
complex rehabilitation needs that require frequent evaluation by a rehabilitation doctor. Services needed may 
be provided safely in a lower level of 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 your 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4342). 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that you need a deep cleaning 
before you can get your partial dentures. The Plan denied your request. The Plan says the requested services are 
not covered by your dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
periodontal scaling and root planing in all four quadrants (D4342).