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

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 11, 2022, to January 30, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were required to 
stay in the hospital. 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 $210 
copayment per day for days 1-6 of each inpatient hospital stay. Your contract with the Plan also clearly says 
that you then pay a $0 copayment per day for any additional days of the same inpatient hospital stay. 
 You have been asked to pay a $210 copayment per day for days 1-6 of the inpatient hospital stay. This 
item/service falls within the inpatient hospital care benefit category. You have not been charged after day six or 
for the day you were discharged. You have been asked to pay a total of $1,260 ($210 copayment per day x 6 
days = $1,260). 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 inpatient hospital stay provided from 
December 11, 2022, to January 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the pneumatic compression device (PCD) was provided 
to the patient in conjunction with a surgical procedure for the prevention of deep vein thrombosis post-
operatively.  
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675).
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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does 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 not considered medically reasonable and necessary based on Medicare guidelines.  Our 
physician reviewer found that the health plans denial should be upheld.  The enrollee does not require the 
intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per 
week of rehabilitative services and regular physician evaluation.  The enrollees care needs can be met at a 
lower level of care (ex. SNF/Subacute Rehab (SAR)). 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on December 9, 2021, billed with 
codes 95886-26 x2, 95910-26, and 95937-26. 
 
You asked the Plan to pay for the testing services provided. You say that the clam is billed correctly and should 
be paid. The Plan denied your request. The Plan says documentation does not support the billed codes. 
 
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 definitions of codes 95886-26 x2, 95910-26, and 95937-26 are; Needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, 
amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more 
nerves or four or more spinal levels (List separately in addition to code for primary procedure), Nerve 
conduction studies; 7-8 studies, and Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. 
 
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 testing services provided. Our reviewer says that 
documentation does not support the billed codes. Our reviewer found the report does not include 
documentation of the services billed. 
 
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 testing services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for testing services provided on December 9, 2021, billed with codes 95886-26 x2, 
95910-26, and 95937-26.
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 for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says a discharge to a lower level 
of care would not be appropriate if the enrollee has ongoing acute care 
needs.  
 
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 still be unstable for transfer and requires 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. The enrollee does not require services at the LTACH that are not already 
available at the current facility. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 7, 2022, billed 
with codes 81401, 81404, 81405, 81406, and 81251. 
 
You asked the Plan to pay for the genetic testing billed. You say that this is medically necessary testing.  The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim.  

The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 7, 2022, billed with codes 81401, 81404, 81405, 81406, and 81251.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311). 
 
You asked the Plan to pre-approve the connection device. You say that the requested connection device is 
medically necessary. The Plan denied your request. The Plan says that an electronic connection device is 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 the connection device. Our reviewer 
says that the requested item/service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the documentation does not support that it is medically necessary to control the 
requested power options through the joystick (drive interface). The enrollee's right upper extremity strength and 
functional ability as evidenced by being independent for feeding should be sufficient to control any power 
options through their own switches.  
 
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 connection device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection device (E2311).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee can benefit from acute inpatient 
rehabilitation. The Plan denied your request. The Plan says an IRF admission is not medically necessary, and 
the enrollee's needs can be met in another setting.  
 
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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Group 2 power wheelchair (K0850). 
 
You asked the Plan to pre-approve a replacement power wheelchair. You say that you are wheelchair bound. 
You say that your wheelchair was stolen while you were out of town. You say that you are stuck in a different 
state as a result. You also say that you need a new wheelchair. The Plan denied your request. The Plan says the 
requested replacement wheelchair cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a replacement power wheelchair have 
been met. Specifically, there were no medical records provided to support the need for a power wheelchair. The 
file also does not include a police report to support the power wheelchair being stolen. Therefore, we decided 
that the Plan does not have to pre-approve a replacement Group 2 power wheelchair (K0850).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ondansetron tablets. 
 
You asked the Plan to pre-approve ondansetron tablets. The Plan denied your request. The Plan says the 
medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve ondansetron tablets.   
Benefits for ondansetron tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 16, 2023, to February 17, 2023. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this was medically 
necessary. 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 $295 
copayment per day, for days 1 to 6 and a $0 copayment per day, for days 7 to 90 for in-network inpatient care.  
 
 You have been asked to pay a $295 copayment for 1 day of for the inpatient hospital stay. You have not been 
charged for any additional days. This item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided from February 16, 2023, 
to February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy 
(interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, 
discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, 
CT), single or multiple levels, unilateral or bilateral; lumbar (0275T). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the records do not show that the enrollee has evidence of lumbar spinal 
stenosis with neurogenic claudication. The Plan states the magnetic resonance imaging (MRI) says that the 
enrollee does not have significant central canal or foraminal narrowing.  
 
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 service. Our physician reviewer 
found there are no imaging studies showing severe stenosis. Surgery is not needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of 
neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any 
method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; 
lumbar (0275T).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve retainer crown, porcelain/ceramic tooth #9, #11 (D6740) and 
pontic, porcelain/ceramic tooth #10 (D6245). 
 
You asked the Plan to pre-approve retainer crowns and pontic. You say that this is medically necessary. The 
Plan denied your request. The Plan says that this is not medically necessary, therefore, placing a fixed 
prosthesis (bridge) on teeth #9-11 does not meet the coverage criteria under the member's supplemental 
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. The Plan covers retainer 
crowns and pontic when the services are medically necessary and reasonable. 
 
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 retainer crowns and pontic. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found coverage for fixed 
bridges are limited to the replacement of a single maxillary anterior tooth or two adjacent anterior mandibular 
teeth. In this case a single maxillary anterior tooth is being replaced. 
 
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 retainer crowns and pontic have been met. Therefore, we decided that the Plan 
has to pre-approve retainer crown, porcelain/ceramic tooth #9, #11 (D6740) and pontic, porcelain/ceramic 
tooth #10 (D6245).  
 
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: 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 for 
the ongoing management of acute care needs for the enrollee. The Plan denied your request. The Plan says all 
services that would be provided in the LTACH are being provided already in the current acute care setting 
already approved.  
 
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 still be unstable and requires additional acute care services 
that can safely be provided at the current facility until more stable and appropriate for transfer. The enrollee 
does not require services at the LTACH that are not already available at the current facility. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37225 billed for date of service December 6, 
2021.  
 
You asked the Plan to pay for the billed services. You say that the documentation supports the billing.  The 
Plan denied your request. The Plan says the billed code 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. 
 
In this case, the CPT Code Manual definition of code 37225 is revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same 
vessel, when performed. 
 We find that CPT code 37225 is not supported in the medical record. Specifically, the records show that 
endovascular techniques were not used due to the findings during the procedure. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 37225 billed for date of service December 6, 2021.