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 your oxygen levels drastically decreased, and you 
were unable to breath due to your current medical condition. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for an IRF admission. 
 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes (A5500) and inserts (A5512). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you bought your own shoes, but 
they do not work. You also say that you have been told a prescription is needed when you go to an orthopedic 
facility. The Plan denied your request. The Plan says the health records reviewed do not show a medical need. 
 
The Plan must follow Medicare rules. Medicare rules say that diabetic shoes and inserts may be covered for enrollees who meet coverage indications within certain categories. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic shoes and inserts  have not been met. Therefore, we decided that the Plan does not 
have to pre-approve diabetic shoes (A5500) and inserts (A5512).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this due to 
worsening heart failure. The Plan denied your request. The Plan says there is not enough evidence showing that 
CardioMEMS is helpful. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there remains a dearth of randomized, blinded clinical studies examining the long-term clinical 
outcomes to establish the value of CardioMEMS in patient management. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the CardioMEMS procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need unlimited transportation trips in 
order to get to all your medical appointments. You also say you should not have to worry about using all the 
rides. The Plan denied your request. The Plan says the available benefit of 72 trips per year has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips, 20 miles or under trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
21, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 95955 and 99360 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the medical records support the medical 
necessity. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated. 

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 99360 has a status indicator of X on the Physician Fee Schedule. This means that the 
code is not payable. We find that CPT code 95955 is not supported in the medical record. This code is used to 
describe an electroencephalogram during non-intracranial surgery, such as a carotid 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 95955 and 99360 billed for date of service December 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92310) provided on December 2, 
2022. 
 
You asked the Plan to pay for the contact lens fitting. You say that you received and paid out of pocket $100 
for a routine eye exam. You also say that you believe the service rendered by an out of network provider, and 
you would expect the insurance to reimburse you 60% ($60) of the charge. The Plan denied your request. The 
Plan says the contact lens fitting is not covered under Medicare, and therefore, is not covered under the Plan.  

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. Specifically, the contact lens fitting is not a covered benefit. Based 
on this information, we decided that the Plan's rules for coverage of the contact lens fitting have not been met. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting (92310) provided on 
December 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 12, 2022, to 
June 14, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. 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 inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.10, described as 
chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 inpatient hospital services at the DRG originally billed. Our reviewer says 
that documentation does not support the billed code. Our physician reviewer found that the enrollee is an 87-
year-old female who presented with symptomatic bradycardia. Vitals in the emergency department showed 
bradycardia and hypoxia on pulse oximetry but was otherwise hemodynamically stable. She did not have 
respiratory distress or have a history of chronic respiratory failure. She was admitted for symptomatic 
atrioventricular block and underwent dual-chamber pacemaker placement. Chronic respiratory failure is not an 
appropriate primary diagnosis here as there was no evidence of such a diagnosis on this admission and as the 
primary diagnosis was atrioventricular block causing bradycardia.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on June 12, 2022, to June 14, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the requested hospital bed is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the requested hospital bed is 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
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 prefer to admit to an acute rehabilitation because 
you were independent before hospitalization and want to return to being independent. The Plan denied your 
request. The Plan says your records do not show that you need to be seen by a rehabilitation doctor at least 
three times a week for evaluation of functional and medical goals and progress. 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires respiratory therapy 
monitoring while starting an aggressive physical therapy program. The Plan denied your request. The Plan says 
the enrollee's status is unstable and is receiving medically necessary acute and/or critical care at the current 
facility. 
 
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 there are no services available at the LTACH that the enrollee requires that are not available at the current 
health care setting being offered by the health plan. Our physician reviewer found the requested LTACH care is 
not considered medically reasonable and necessary in this case.  
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 pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that your home has 2 sets of stairs to get to 
your car. You have to carry your oxygen tank down 2 sets of stairs. This takes an extraordinary amount of 
energy for you. The Plan denied your request. The Plan says there is no documentation that the standard 
portable oxygen system, the portable oxygen E-cylinder gaseous tanks provided, does not meet the enrollee's 
medical needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have standard portable oxygen system, portable oxygen E-cylinder gaseous tanks. The 
standard portable oxygen system, portable oxygen E-cylinder gaseous tanks, serves the same purpose as the 
requested oxygen equipment. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator (E1392).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed side rails (E0310). 
 
You asked the Plan to pre-approve bed side rails. You say that you do not have a hospital bed because you do 
not need one. You also say that you have no money, and would like a bed assisted bed rail to be covered by the 
Plan. The Plan denied your request. The Plan says the information does not show you have a hospital bed. The 
Plan also says that you do not meet medical necessity based on the NCD coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that bed side rails can be covered when an integral 
part of, or an accessory to, a hospital bed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of bed side rails have not been met. Therefore, we decided that the Plan does not have to pre-approve 
bed side rails (E0310).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 27, 2021, billed with 
codes 81408-59, 81479, 81408, 81407, 81406-59, 81406, 81405-59, 81405, 81404-59, 81404-59, 81404-59, 
81404-59, 81404, 81403-59, 81403-59, 81403, 81401-59, 81401, 81400, 81286, and 81256. 
 
You asked the Plan to pay for the genetic testing billed. You say that please find the attached medical records 
that support the services as it was not experimental and investigational. 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 
May 27, 2021, billed with codes 81408-59, 81479, 81408, 81407, 81406-59, 81406, 81405-59, 81405, 81404-
59, 81404-59, 81404-59, 81404-59, 81404, 81403-59, 81403-59, 81403, 81401-59, 81401, 81400, 81286, and 
81256.
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 enrollee's medical management and rehabilitation 
needs require an inpatient rehabilitation stay and close physician supervision. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for admission to an Inpatient Rehabilitation 
Facility. 
 
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 the enrollee's 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: 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 need additional rehabilitation and medical 
supervision. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission 
to an Inpatient Rehabilitation Facility. 
 
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: 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. The Plan denied your request. The Plan says the enrollee does not 
meet all the required Medicare criteria for admission to an Inpatient Rehabilitation Facility.  
 
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 the enrollee's 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation 
 
You asked the Plan to pre-approve additional routine transportation. You say that you have cancer and need 
additional trips. The Plan denied your request. The Plan says you have exhausted your routine transportation 
benefit for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 10 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation