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

 
We decided that the Plan does not have to pay for the inpatient hospital stay provided on June 22, 2023, to June 
24, 2023. 
 
You asked the Plan to pay for the inpatient hospital stay. You say that you are requesting reconsideration for 
the services provided. 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 the inpatient hospital 
stay provided on June 22, 2023, to June 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
January 9, 2023. 
 
You asked the Plan to pay for the urine PCR panel. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the urine PCR panel. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that urine PCR is an unnecessary test. Urinalysis with culture is sufficient for testing. 
 
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 urine PCR panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine polymerase chain reaction (PCR) panel provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a pontic (D6240) for tooth #10. We decided that the Plan does not 
have to pre-approve a custom fabricated abutment (D6057) for tooth #7, #11, and #12, an abutment supported 
to crown (D6059) for tooth #12, an abutment supported to retainer (D6069) for tooth #7 and #11.  
 
You asked the Plan to pre-approve a custom fabricated abutment (D6057) for tooth #7, #11, and #12, an 
abutment supported to crown (D6059) for tooth #12, an abutment supported to retainer (D6069) for tooth #7 
and #11, and a pontic (D6240) for tooth #10. You say that you need the dental services approved so you can 
finish your dental treatment that you have been doing since last year. The Plan says that your benefit for the 
requested items or services has already been exhausted. 
 
We decided that the Plan has to pre-approve a pontic (D6240) for tooth #10.  
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the pontic was previously exhausted. 
Therefore, we decided that the Plan has to pre-approve a pontic (D6240) for tooth #10.  
 
We also decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for 
tooth #7, #11, and #12, an abutment supported to crown (D6059) for tooth #12, an abutment supported 
to retainer (D6069) for tooth #7 and #11. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan pre-approved a custom fabricated abutment (D6057) for tooth #5 and #6 and an abutment 
supported to crown (D6059) for tooth #5, and an abutment supported to retainer (D6069) for tooth #6 on July 
31, 2023; therefore, your benefit for implants was exhausted on the date of approval of July 31, 2023. 
Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for 
tooth #7, #11, and #12, an abutment supported to crown (D6059) for tooth #12, an abutment supported to 
retainer (D6069) for tooth #7 and #11. 
  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis panel identified 
with code 81456. 
 
You asked the Plan to pre-approve targeted genomic sequence analysis panel identified with code 81456. You 
say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services 
are not medically necessary. 
 
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 targeted genomic sequence analysis 
panel identified with code 81456. 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 a history of 
Metastatic Endometrial carcinosarcoma. Metastatic Endometrial carcinosarcoma. The enrollee has undergone a genetic test performed called Tempus xT identified with code 81455. While the enrollee has a 
diagnosis/condition that would meet criteria for the requested services, the enrollee has received testing and 
therefore, does not meet criteria for the requested testing in addition to the testing approved by the plan (code 
81455). Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of targeted genomic sequence analysis panel identified with code 81456 have not 
been met. Therefore, we decided that the Plan does not have to pre-approve targeted genomic sequence 
analysis panel identified with code 81456.
Appeal type: Practitioner Services
Decision: Unfavorable

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

 
We decided that the Plan does not have to pay for the lab panel provided on February 10, 2023. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says there is a more 
appropriate code for the services provided. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. The testing in this case was billed with multiple codes and not one 
code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 
the panel have not been met. Therefore, we decided that the Plan does not have to pay for the lab panel 
provided on February 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided on July 19, 2023. 
 
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says this claim was not billed with the appropriate Type of Bill code. 
 The Plan must follow Medicare rules. Medicare rules say that the accepted Type of Bill codes for home health 
prospective payment system claims are 0327, 0328, or 0329.  
 
We looked at the file and Medicare rules. This claim was billed with Type of Bill code 0322 which is not 
acceptable. Based on this information, we decided that Medicare rules for coverage of home health care have 
not been met. Therefore, we decided that the Plan does not have to pay for home health care provided on July 
19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment provided on April 18, 2023. 
 
You asked the Plan to pay for oxygen equipment. You say that this was medically needed and you want it 
covered. 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 oxygen equipment 
provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee-shin system stance flexion feature (L5845). 
 
You asked the Plan to pre-approve stance flexion feature. You say that the knee cannot function without this 
component. The Plan denied your request. The Plan says that this request is duplicative given the prosthetic 
already has a flex stance feature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve stance flexion feature. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records provided are more than sufficient to satisfy the Medicare 
documentation requirements for this component. The L5845 code describes an adjustable stance flexion 
feature, which is separate and distinct from the static support provided regardless of gait phase anticipated in 
L5812 by itself.  Moreover, L5845 is expressly allowed as an addition code to L5812.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stance flexion feature have been met. Therefore, we decided that the Plan has to 
pre-approve a knee-shin system stance flexion feature (L5845).  
 
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 pre-approve outpatient services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve outpatient services. You say that your chosen provider has treated other 
people from your Plan and that your Plan card stating that no referral is required for coverage. The Plan denied 
your request. The Plan says that their first decision to deny coverage was correct. 
 
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 
outpatient services to be provided by an out-of-network (OON) provider.   
 
Your complaint about your Plan card stating that no referral is required for coverage is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691), hip 
orthosis (L1686, and hip abductor (L2624), purchased on April 25, 2023. 
 
You asked the Plan to pay for the UV light therapy system, hip orthosis, and hip abductor. You say that the 
items should be covered. The Plan denied your request. The Plan says the documentation requirements have 
not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.   
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. There is no indication these items were needed or ordered in the medical records submitted. The 
record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the ultraviolet (UV) light therapy system (E0691), 
hip orthosis (L1686, and hip abductor (L2624), purchased on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam provided on July 20, 2023. 
 
You asked the Plan to pay for the eye exam. You say that you are appealing the denial with supporting 
documentation. 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 the eye exam provided 
on July 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided on February 14, 2023, billed with 
procedure code 93306.  
 
You asked the Plan to pay for the imaging services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says documentation does not support the billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 93306 is echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler 
echocardiography, and with color flow Doppler echocardiography. 
 
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 imaging services provided. Our reviewer says that 
documentation does not support the billed code. Our reviewer found that the procedure report does not include 
sufficient documentation to confirm a complete echocardiography has been performed.  A completed 
transthoracic echocardiogram (TTE) requires real-time imaging and documentation of 2D and M-mode images 
of the bilateral atria and ventricles; spectral and color doppler over the aortic, mitral, tricuspid, pulmonic 
valves; and evaluation of the pericardium and adjacent portions of the aorta. This criterion was not found in 
medical record and therefore 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 imaging services provided have not been met. Therefore, we decided that 
the Plan does not have to pay for imaging services provided on February 14, 2023, billed with procedure code 
93306.
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 services are medically necessary due 
to the enrollee's multiple medical issues and comorbidities that are too complicated for a skilled nursing 
facility. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current 
setting. 
 
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 appears to be improving with current treatment and should only require 
short-term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care soon. The enrollee does not require services at the LTACH that 
are not already available at the current facility.  
 
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 you disagree with the denial for the 
admission to a LTACH. The Plan denied your request. The Plan says the enrollee can reasonably receive their 
continued care needs in their current setting. 
 
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 does not require services at the LTACH that are not already available at 
the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous positive airway pressure (CPAP) machine 
supplies provided on June 09, 2023. 
 
You asked the Plan to pay for continuous positive airway pressure (CPAP) machine supplies. You say that you 
are in-network for all plans. This should be covered, especially as this is 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 continuous positive 
airway pressure (CPAP) machine supplies provided on June 09, 2023.