Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says this system is not medically reasonable 
and necessary for the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that an IPV in the home setting is 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 Volara system. Our reviewer says that this system is not medically necessary. Our physician reviewer found that the record indicates that the 
enrollee has obstructive sleep apnea. The requested intrapulmonary percussive device is being used in the home 
setting. The elements of the coverage criteria are not satisfied. The requested service is not 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 Volara system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the Volara system.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061-26-LT billed for date of service June 
6, 2023. 
 
You asked the Plan to pay for procedure code 77061-26-LT. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 77061-26-LT has a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code 77061-26-LT is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure code 77061-26-LT have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 77061-26-LT billed for date of service June 6, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on April 12, 2023, billed with 
codes 87481, 87652 and 87798 (x13). 
 
You asked the Plan to pay for the laboratory panel billed. You say that this test was necessary and is supported 
in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on April 12, 2023, billed with codes 87481, 87652 and 87798 (x13).
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 as they require extensive pulmonary hygiene, ventilation weaning and pulmonary oversight. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is 
currently unstable for transfer to an LTACH. 
 
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 review has determined that there is no documentation provided indicating 
medical necessity for admission to a LTACH. The enrollee does not require services at the LTACH that are not 
available at the acute care hospital where they are currently receiving care. The requested LTACH services are 
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to 
be furnished safely and effectively only on an inpatient basis. 
 
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 procedure code 81456 billed for date of service March 9, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that this service was billed appropriately and is 
separately payable. The Plan denied your request. The Plan says payment for code 81456 is bundled into 
payment for code 81455. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 81456 billed for date of service March 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that this item is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 the home ventilator. Our reviewer says 
that the home ventilator is not medically necessary. Our physician reviewer found there is no evidence or data 
provided within the documentation to support initiation of a home ventilator. The records do not show trial and 
failure of a Continuous Positive Air Pressure (CPAP) unit or BiPAP unit. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve neurostimulation (C1778, C1787, 
C1767, 64582). 
 
You asked the Plan to pre-approve hypoglossal nerve neurostimulation. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve neurostimulation is considered 
medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea when the 
enrollee has a body mass index (BMI) less than 35 kg/m2. 
 
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 hypoglossal nerve neurostimulation. 
Our reviewer says that this service was medically necessary. Our physician reviewer found the enrollee has a 
BMI of 36.32. Medicare coverage criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hypoglossal nerve neurostimulation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve hypoglossal nerve neurostimulation (C1778, C1787, C1767, 64582).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy treatment and a specialist visit provided on 
June 14, 2023, by an out-of-network provider. 
 
You asked the Plan to pay for chemotherapy treatment and a specialist visit. You say that you were out of the 
state and unable to travel back home to receive treatment from an in-network provider. 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 there is a 
point-of-service (POS) plan coverage limit of $5,000 per calendar year. Once this limit is reached, you are 
responsible for 100% of the cost of out-of-network services.  
 You have been asked to pay 100% of the cost of out-of-network services for chemotherapy treatment and a 
specialist visit. 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 pay for chemotherapy treatment and a specialist visit provided on 
June 14, 2023, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on April 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was needed in order to get 
treatment options and see if a root canal was necessary.  The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
consultation (D9310) provided on April 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the trigger finger surgery and the facility 
charges provided on June 1, 2023. 
 
You asked the Plan to waive the cost share for the surgery services. You say that you disagree with the provider 
and the facility charges. 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. Your 
contract with the Plan says that there is a $675 deductible which applies to outpatient hospital services. Your 
contract with the Plan also clearly says that you must pay a $350 copayment for surgery services. 
 
 
 
 You have been asked to pay $482.06 towards your deductible for the provider services. You have also been 
asked to pay $175.40, which satisfies your deductible for the facility charges. The items or services you asked 
the Plan to waive the cost share for fall within the outpatient hospital services benefit category. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $675 deductible which applies to 
outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time the 
surgery services was received on June 1, 2023.  
 
You have also been asked to pay a $350 copayment for the facility charges. This item/service falls within the 
outpatient hospital services 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 cost share for the trigger 
finger surgery and the facility charges provided on June 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 28, 2023, by an OON 
provider.  
 
You asked the Plan to pay for the genetic testing. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 genetic testing provided on January 28, 2023, 
by an OON provider.
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 have had multiple medical issues and if your 
heart acts up while at a SNF, you will have to go back to the hospital. The Plan denied your request. The Plan 
says the IRF care is not medically necessary and your needs can be met at a lower level of care such as a skilled 
nursing 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 you were admitted for sepsis and cellulitis. Your medical problems are stable, and 
there are no complex nursing or rehabilitation needs. 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 and/or occupational therapy, there is no documented 
need for intensive rehabilitation 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 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 office visit provided by a chiropractor on May 16, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says The Plan says that an office visit is not a covered benefit when billed by a 
chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on May 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on May 
30, 2023. 
 
You asked the Plan to pay for the dental service. You say that the images taken by this dentist were not like the 
regular x-ray taken in the other dentist's office. You also say that these were important to have a more extensive 
view of the problem. The Plan denied your request. The Plan says your benefit for the panoramic radiographic 
image has already been exhausted. 
 
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 your benefit for the panoramic radiographic image was exhausted on date of service April 13, 2023. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) 
provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies, and needle electromyography 
provided by a chiropractor on July 18, 2023. 
 
You asked the Plan to pay for the nerve conduction studies and needle electromyography. You say that you 
were told that you needed this test completed. The Plan denied your request. The Plan says The Plan says the 
only covered chiropractic service is manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the nerve conduction studies (95913) and needle electromyography (95886) 
provided by a chiropractor on July 18, 2023.
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's records do not show to require three hours of therapy a day at least five days a 
week. The Plan also says that the 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 that 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.  
 
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says the IRF care is not medically necessary, and the enrollee's needs can be met at a 
lower level of care such as a skilled nursing facility, on an intermittent basis at home with home health care, or 
in a long-term care 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 the enrollee was admitted for fatigue and COVID-19 infection. The enrollee's 
medical problems are stable, and there are no complex nursing or rehabilitation needs. The enrollee does 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 and/or 
occupational therapy, there is no documented need for intensive rehabilitation 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 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.