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

 
We decided that the Plan does not have to pre-approve  an inpatient hospital admission. 
 
You asked the Plan to pre-approve  the inpatient hospital admission. You say that the enrollee has a massive 
rotator cuff tear which cannot be repaired. You say that the records provided support the need for an inpatient 
admission.  The Plan denied your request. The Plan says there is no documentation that the enrollee would 
require a greater than two midnight stay.  
 
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 pre-approve the inpatient hospital admission. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the record 
indicates that the enrollee is scheduled for e left reverse total shoulder arthroplasty.  The record provided does 
not indicate that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
midnights, taking into account complex medical factors. The initial day may be spent in observation until it is 
clearly expected that a second midnight would be required, at which time the physician may order inpatient 
admission. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pre-approve  an inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (87481, 87640, 87652, 87798) 
provided on January 9, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records provided. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87481 is infectious agent detection by nucleic acid (DNA 
or RNA); Candida species, amplified probe technique.  

The definition of code 87640 is infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus 
aureus, amplified probe technique. The definition of code 87652 is infectious agent detection by nucleic acid 
(DNA or RNA); Streptococcus, group A, quantification. The definition of code 87798 Is infectious agent 
detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. 
 
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 laboratory services. Our reviewer found there is no 
documentation to support procedure codes 87481, 87640, 87652, 87798 for date of service January 9, 2023. 
The provided records in this case do not specifically document testing for 87481, 87640, 87652, 87798. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (87481, 87640, 87652, 87798) provided on January 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation with a custom 
implant (20985). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation. You say that you are requesting 
reconsideration of the denied authorization. The Plan denied your request. The Plan says the requested service 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve computer-assisted surgical navigation. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that there is no large volume, long-term/high-quality clinical studies 
that confirm the clinical benefits (ultimate outcomes of functional improvement and pain reduction) of 
computer-assisted surgery over standard surgical approaches in reverse total shoulder arthroplasty. No 
compelling rationale is presented, or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of computer-assisted surgical navigation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve computer-assisted surgical navigation with a custom implant 
(20985).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for the office visit provided on January 30, 2023. 
 
You asked the Plan to waive the cost share the physician service. You say that the enrollee has dual coverage. 
You also say that this should be paid in full. The Plan denied your request. The Plan says that 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). The enrollees contract with the Plan says that enrollees must pay a 
$0 copayment for Physician services.  
 
The Plan says the enrollee must pay a coinsurance for the physician service. Based on the plan contract, 
however, the enrollee cannot be asked to pay more than a $0 copayment for the physician service. Therefore, 
we decided that the Plan has to waive the cost share for the office visit provided on January 30, 2023.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided January 23, 2022, to 
February 21, 2022, and August 9, 2022, to September 7, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 23, 2022. The NOA was not received by the Plan until March 10, 
2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health services 
provided January 23, 2022, to February 21, 2022, and August 9, 2022, to September 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hemoglobin; glycosylated (A1C) provided on 
December 29, 2022. 
 
You asked the Plan to pay for hemoglobin; glycosylated (A1C). You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services are not authorized because hemoglobin; 
glycosylated (A1C) is not a Medicare benefit for the diagnoses listed on the claim and is done for screening 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that glycated hemoglobin/protein testing is widely 
accepted as medically necessary for the management and control of diabetes. It is also valuable to assess 
hyperglycemia, a history of hyperglycemia or dangerous hypoglycemia. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hemoglobin; glycosylated (A1C) have not been met. Therefore, we decided that the Plan does not 
have to pay for hemoglobin; glycosylated (A1C) provided on December 29, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chest x-ray provided on November 28, 2022. 
 
You asked the Plan to pay for a chest x-ray. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a chest x-ray provided 
on November 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87652 billed for date of service January 6, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says the lab results do not support the code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87652 is infectious agent detection by nucleic acid (DNA 
or RNA); Streptococcus, group A, quantification. 

We find that CPT code 87652 is not supported in the medical record. Specifically, there is a more applicable 
code that describes the services provided. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87652 billed for date of service January 6, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service (A0427-SW) provided on December 
5, 2022. 
 
You asked the Plan to pay for the ambulance service . You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations.  
 
The Plan must follow Medicare rules. There is a list of valid origin/destination modifiers for ambulance 
services in the Medicare Claims Processing Manual, the code that was used was "W" and it is not listed in the 
Medicare rules has a correct modifier; therefore, "W" is not considered valid. We looked at the file and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance 
service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service 
(A0427-SW) provided on December 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye ultrasound provided on August 25, 2022. 
 
You asked the Plan to pay for an eye ultrasound. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an eye ultrasound 
provided on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator for 9 months (E0466). 
 
You asked the Plan to pre-approve a ventilator for 9 months. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, 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. 
 
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 ventilator for 9 months. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found continuation of the home 
ventilator is not medically necessary. It appears the enrollee's needs could be met with bilevel positive airway 
pressure (BiPAP) with average volume-assured pressure support (AVAPS) during sleep. Medicare does not 
cover a home ventilator when used at settings that can be provided with BiPAP. Of note, the plan has approved 
the ventilator for an additional 3 months to allow time for transition to BiPAP. 
 
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 ventilator for 9 months have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a ventilator for 9 months (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cup holder and cup holder bracket. 
 
You asked the Plan to pre-approve a cup holder and cup holder bracket. You say that the enrollee is at greater 
risk for falls and breakdown. The Plan denied your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.    

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a cup holder and cup holder bracket.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty at L1 (22514). 
 
You asked the Plan to pre-approve a kyphoplasty. You say that you are requesting reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PVA is covered if all of the criteria listed in the 
Medicare rules section 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 a kyphoplasty. Our reviewer says that 
the coverage criteria has not been met. Our physician reviewer found that the detailed documentation is not 
evident regarding painful, debilitating, osteoporotic vertebral collapse/compression fractures, defined as those 
that have not responded to non-surgical medical management (e.g. narcotic and/or non- narcotic medication, 
physical therapy modalities) with and without methods of immobility (e.g. rest, bracing). Additionally, there is 
no documentation of worsening pain, progression of vertebral body height loss, kyphotic deformity, or severe 
impact of VCF on daily functioning. Moreover, the pain is likely multifactorial, with multilevel degenerative-
type disease in the lumbar spine.  
 
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 kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a kyphoplasty at L1 (22514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapy visit provided on November 23, 2022. 
 
You asked the Plan to pay for a therapy visit. You say that this was medically necessary and should be covered. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a therapy visit provided 
on November 23, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a therapy office visit provided on September 09, 2022. 
 
You asked the Plan to pay for a therapy office visit. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a therapy office visit 
provided on September 09, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 9, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that as a part of your recovery from knee 
surgery you were prescribed a bunch of medications to assist in your recovery. The Plan denied your request. 
The Plan says that self-administered drugs do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
on January 9, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a joint injection, and related services provided on October 
07, 2022. 
 
You asked the Plan to pay for a joint injection, and related services. You say that this is supported in the 
records. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a joint injection, and 
related services provided on October 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment the medical eye examination provided on 
February 24, 2023. 
 
You asked the Plan to waive the copayment the medical eye examination. You say that you had a routine eye 
exam, including a refraction and dilation. You say you were improperly charged a $35 copayment. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for Medicare-covered vison services at an in-network specialist's office.  
 
 You have been asked to pay a $35 copayment for the medical eye examination. The medical eye examination 
falls within the vision care benefit category. The record shows a diagnosis of disorders of the eyelid which 
makes the eye examination medical in nature. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment the medical eye 
examination provided on February 24, 2023.