Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology procedures of the gastrointestinal tract, 
radiologic examination, spine, cervical, x-ray exam of jaw, radiologic examination, of teeth, radiologic 
examination of chest, radiologic examination, gastrointestinal tract, upper provided on December 20, 2022. 
 
You asked the Plan to pay for diagnostic radiology procedures of the gastrointestinal tract, radiologic 
examination, spine, cervical, x-ray exam of jaw, radiologic examination, of teeth, radiologic examination of 
chest, radiologic examination, gastrointestinal tract, upper. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were performed at a nursing home (via mobile 
van/portable x-ray), which are denied as an excluded place of service. 
 
The Plan must follow Medicare rules. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of diagnostic radiology procedures of the gastrointestinal tract, radiologic examination, spine, 
cervical, x-ray exam of jaw, radiologic examination, of teeth, radiologic examination of chest, radiologic 
examination, gastrointestinal tract, upper have not been met. Therefore, we decided that the Plan does not have 
to pay for diagnostic radiology procedures of the gastrointestinal tract, radiologic examination, spine, cervical, 
x-ray exam of jaw, radiologic examination, of teeth, radiologic examination of chest, radiologic examination, 
gastrointestinal tract, upper provided on December 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services rendered from 
November 12, 2021, to November 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that there is no evidence to support 
that the enrollee was diagnosed with or treated for malnutrition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for skilled nursing facility (SNF) services rendered from November 12, 2021, to November 30, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided February 27, 2023, through March 
3, 2023, from an out-of-area (OOA) provider.  
 
You asked the Plan to pay for inpatient hospital services provided February 27, 2023, through March 3, 2023, 
from an OOA provider. . You say that the records provided support the services in dispute.  The Plan denied 
your request. The Plan says that medically necessary care was available in the service area. The Plan says that 
it would not have been expected that waiting until the enrollee returned to the service area would have resulted 
in a significant decline in their health.  
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 inpatient hospital services provided February 
27, 2023, through March 3, 2023, from an OOA provider. Our reviewer says that the criteria for coverage of 
OOA care have been met.  Our physician reviewer found the records describe the enrollee as presenting to the 
emergency department (ED) with intractable abdominal pain and hypocalcemia. After hypocalcemia, 
hypokalemia, hypomagnesemia, and acidosis were treated, she was admitted to observation status at first then 
transferred to inpatient status due to uncontrolled pain requiring intravenous (IV) medications. She was also 
noted to have leakage around her ostomy site and still was only tolerating a liquid diet at the time with 
malnourishment. The enrollee could not have foreseen requiring the services prior to leaving the service area. 
The records indicate that the care provided was medically necessary. It would not have been medically 
reasonable to delay the services until returning to the service area.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital services provided February 27, 2023, through March 3, 2023, 
from an OOA provider.  have been met. Therefore, we decided that the Plan has to pay for inpatient hospital 
services provided February 27, 2023, through March 3, 2023, from an out-of-area (OOA) provider.   
 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an 
Inpatient Rehabilitation Facility. 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 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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location 
until such time no further acute level care is needed. 
 
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 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. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services rendered from May 1, 2022, to May 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the care could have been provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services rendered from May 1, 2022, to May 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation services (99199, 99499) provided on January 
2, 2023, through February 27, 2023. 
 
You asked the Plan to pay for the evaluation services. You say that the services should be covered. The Plan 
denied your request. The Plan says these services were obtained through a provider that 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 pay for the evaluation services (99199, 99499) 
provided on January 2, 2023, through February 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 1, 2022, billed 
with codes 81220, 81225, 81226, 81227, 81231, 81232, 81247, 81283, 81306, 81328, 81335, 81350, 81381, 
81381-XU, 81401, 81401-XU, 81355, 81291, 81240, 81241, 81230, and 81346. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 1, 2022, billed with codes 81220, 81225, 81226, 81227, 81231, 81232, 81247, 81283, 81306, 81328, 
81335, 81350, 81381, 81381-XU, 81401, 81401-XU, 81355, 81291, 81240, 81241, 81230, and 81346.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from March 15, 2022, to 
April 13, 2022. 
 
You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says rules for payment for home health services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan of care must be signed and dated by a 
physician or allowed practitioner before the claim for each 30-day period for services is submitted for the final 
percentage payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health services have not been met. Specifically, the case record does not support that the plan 
of care was signed and dated before the claim for services at issue was submitted to the Plan. Therefore, we decided that the Plan does not have to pay for home health services provided from March 15, 2022, to April 13, 
2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Ottobock Taleo Vertical Shock foot and Ottobock Dynion knee.  
You asked the Plan to pre-approve Ottobock Taleo Vertical Shock foot and Ottobock Dynion knee. You say 
that the services are necessary. The Plan denied your request. The Plan says that based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 Ottobock Taleo Vertical Shock foot and 
Ottobock Dynion knee. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the records are explicit that his residual limb has decreased in size now a year out from resuming 
ambulation, rendering his socket ill-fitting, and that he is a K3 ambulator as a result of working hard at his own 
rehabilitation. Medicares policy recognizes that microprocessor knees and flex-walk feet are part of the basic 
standard of care for all community above knee amputee ambulators given that the evidence of their benefits and 
superiority to less sophisticated alternatives are so well proven and long standing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ottobock Taleo Vertical Shock foot and Ottobock Dynion knee have been met. 
Therefore, we decided that the Plan has to pre-approve Ottobock Taleo Vertical Shock foot and Ottobock 
Dynion knee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroplasty (0200T). 
 
You asked the Plan to pre-approve sacroplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been 
met. 
 
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 sacroplasty. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found sacroplasty is experimental in cases of sacral insufficiency lesions. More research is 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 sacroplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroplasty (0200T).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left knee unilateral 
primary osteoarthritis. He has not tried and failed the Plan's required drugs, Orthovisc, Supartz FX, Durolane, 
Monovisc, or Synvisc-One. The records do not show that the required drugs would be contraindicated or less 
effective; therefore, Euflexxa is not reasonable or medically necessary. 
 
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 pre-approve Euflexxa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided 
March 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says your benefit for the requested item or service 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 requested item or service was exhausted on date of service November 22, 2022, and 
December 9, 2022. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root 
planing (D4341) provided March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that the requested scooter is medically necessary. 
The Plan denied your request. The Plan says you do not meet the medical necessity and established criteria for 
the requested powered scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 
 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 power scooter. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the requested device is not necessary 
to perform MRADLS in your home. 
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter (K0800).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Cyanocobalamin solution. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the 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. The Plan has not provided any medical records from your neurologist or other 
network provider. Without medical records, a determination based on medical necessity cannot be supported. 
Therefore, we decided that the Plan has to pre-approve Cyanocobalamin solution.  
 
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 pay for the acute inpatient hospital care provided October 4, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee went for a total knee arthroplasty, and this is 
an outpatient surgery. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found documentation did not clearly show the enrollee having an unstable condition or at 
high risk for complication to expect hospitalization would be 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided October 4, 2022.