Persius/hicric huggingface dataset:
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 services are medically necessary for the enrollee 
to receive the care needed. The Plan denied your request. The Plan says the enrollee does not meet the criteria 
for admission to an IRF.  
 
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 enrollee does not require the intensity of services provided at an IRF. 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. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 24, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 24, 2023.
Appeal type: ER
Decision: Partially Favorable

 
We decided that the Plan has to lower the copayment for emergency room services. We decided that the Plan 
does not have to waive the copayment for emergency room services.  
 
You asked the Plan to waive the copayment for emergency room services provided on October 4, 2022. You 
say that you disagree with the copayment. The Plan says that this cost sharing was charged correctly.  
We decided that the Plan has to lower the copayment for emergency room services.  
 
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a $90 copayment for 
emergency room visit. 
 
The Plan says you must pay $365 for emergency room service. Based on the Plan contract, however, you 
cannot be asked to pay more than a $90 copayment for emergency care.  
 
We also decided that the Plan does not have to waive the copayment for emergency room services. 
 
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 $90 
copayment for emergency room services. Therefore, we decided that the Plan does not have to waive the 
copayment for emergency room 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (0241U) provided on February 21, 2023. 
 
You asked the Plan to pay for the laboratory test. You say that this test is supported in the medical record. The 
Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (0241U) 
provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1843) and suspension sleeve (L2397). 
 
You asked the Plan to pre-approve a knee brace and suspension sleeve. You say that the items are medically 
necessary. The Plan denied your request. The Plan says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and 
extension joint that provides both medial-lateral and rotation control (L1843), are covered if the beneficiary has 
had recent injury to or a surgical procedure on the knee (s). Knee orthoses are also covered for a beneficiary 
who is ambulatory and has knee instability.  
 
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 knee brace and suspension sleeve. 
Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee has a 
diagnosis of bilateral knee osteoarthritis but there is no indication of a recent knee injury or surgery. The 
physical examination also does not indicate instability of the knee joints. 
 
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 knee brace and suspension sleeve have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a knee brace (L1843) and suspension sleeve (L2397).
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 services are necessary for the enrollee's fracture 
of the tibia. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to 
an IRF.  
 
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 enrollee does not require the intensity of services provided at an IRF. 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. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatments (98941) provided 
from February 11, 2022, through December 30, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the chiropractic services provided were not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to 
correct a subluxation.   
 
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 these services. Our reviewer says that the 
chiropractic services provided were not medically necessary. Our physician reviewer found that in this case, the 
record indicates that you have back, elbow, arm, and hip pain. The records provided do not document the 
presence of a subluxation of the spine either by physical examination or radiographic images. The records of 
these visits do not support progressive improvement of symptoms but rather maintenance therapy. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
services provided. The elements of the coverage criteria are not satisfied.    
 
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 pay for the chiropractic manipulative treatments (98941) provided from February 11, 2022, through 
December 30, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88360 billed for date of service December 
14, 2022.  
 
You asked the Plan to pay for procedure code 88360. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says the number of units billed 
exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 88360 is 6. The MAI value for this code is 3. You billed 8 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88360 billed for date of service December 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a partial psychiatric hospitalization. 
 
You asked the Plan to pre-approve a partial psychiatric hospitalization. You say that these hospital services are 
medically necessary. The Plan denied your request. The Plan says that the requested services are not medically 
necessary. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Medical records were not provided. Therefore, we decided that the Plan has to 
pre-approve a partial psychiatric hospitalization.  
 
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 pay for the AVISE CTD test genetic panel (0312U) provided August 
4, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that please see the attached documents and below 
information regarding the test that was deemed medically necessary by the enrollee's physician. The Plan 
denied your request. The Plan says AVISE CTD test panel is considered experimental and investigational, as it 
is unproven to alter disease prognosis or treatment outcomes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Screening genetic testing is not a covered service under Medicare. This testing is unproven to alter disease prognosis or treatment outcomes. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the AVISE CTD test genetic panel (0312U) provided August 4, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) of the neck 
(70549). 
 
You asked the Plan to pre-approve an MRA of the neck. You say that you want the Plan to approve this 
service. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are 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 an MRA of the neck. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee by record had negative 
magnetic resonance imaging (MRI) of the brain one year ago. There is no duplex ultrasound scan of the neck 
on record. The medical necessity of the requested MRA of the neck is not detailed in the submitted records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the neck have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a magnetic resonance angiography (MRA) of the neck (70549).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a permanent peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a permanent peripheral nerve stimulator. You say that this is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet the Plan criteria for 
coverage. 
 
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 permanent peripheral nerve 
stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is no trial documented. A trial is needed with 
documented pain relief. 
 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 permanent peripheral nerve stimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a permanent peripheral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99205 for date of service March 8, 2023. 
 
You asked the Plan to pay for procedure code 99205. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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 CPT code 99205 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes M54.2 (Cervicalgia) and M50.30 (Other cervical disc degeneration, unspecified cervical 
region). These diagnosis codes should not be reported together. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99205 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99205 for date of service March 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83036, 80061, 83525, 80053, 84436, 
84443, 84481) provided on March 16, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was in a nursing home at the 
time the services were rendered and required to use this lab. The Plan denied your request. The Plan says these 
services are not covered when provided OON. Additionally, the Plan states that they do not have evidence that 
the enrollee was in a nursing facility. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (83036, 80061, 83525, 
80053, 84436, 84443, 84481) provided on March 16, 2023, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 19, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 82306, 82607 and 82746 
provided June 30, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that you tried to contact the physician office for 
correct diagnosis but were not able to obtain this information timely. Please reprocess your claim for payment. 
The Plan denied your request. The Plan says the claim was filed past the timely filing limitation. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory service was not filed until February 23, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 82306, 82607 and 82746 
provided June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical procedures to remove unwanted fat from the 
body. 
 
You asked the Plan to pre-approve surgical procedures to remove unwanted fat from the body.. You say that 
the service is medically necessary. The Plan denied your request. The Plan says this provider is not enrolled in 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pre-approve surgical procedures to remove 
unwanted fat from the body.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a freestyle libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met.  Therefore, we 
decided that the Plan does not have to pre-approve a freestyle libre 2 continuous glucose monitor (CGM).