Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation (97161), gait training therapy 
(97116) and therapeutic activities (97350) provided on May 30, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy evaluation, gait training therapy and therapeutic activities. You 
say that the services rendered were medically necessary. The Plan denied your request. The Plan says prior 
authorization must be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 physical therapy evaluation (97161), gait 
training therapy (97116) and therapeutic activities (97350) provided on May 30, 2020 by an out of network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Mohs micrographic technique and additional stage provided 
on June 2, 2020. 
 
You asked the Plan to pay for Mohs micrographic technique (17311) and additional stage (17312). You say 
that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted 
did not include documentation of pathological findings for each stage/specimen obtained. 
 
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 17311, 17312 is Mohs micrographic technique, including 
removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, 
microscopic examination of specimens by the surgeon, and histopathologic preparation including routine 
stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with 
surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue 
blocks and MOHS ADDL STAGE. 
 
We find that CPT code 17311, 17312 is not supported in the medical record. Specifically, there is no 
documentation of microscopic findings. Based on this information, we decided that Medicare rules for 
coverage of Mohs micrographic technique (17311) and additional stage (17312) have not been met. Therefore, 
we decided that the Plan does not have to pay for Mohs micrographic technique and additional stage provided 
on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive Genomic Profile testing provided on 
March 27, 2020. 
 
You asked the Plan to pay for the Comprehensive Genomic Profile testing. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Comprehensive Genomic Profile testing is not supported in the medical record. Specifically, 
this service requires the use of code 81479. In addition, the appropriate DEX Z Code identifier should be 
entered adjacent to the code in the comment/narrative field. Based on this information, we decided that 
Medicare rules for coverage of the Comprehensive Genomic Profile testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Comprehensive Genomic Profile testing provided on March 
27, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe supplies for maintenance of non-insulin drug infusion catheter, infusion supplies, and Milrinone lactate injection provided from March 26, 2020, to April 1, 2020.You asked the Plan to pay forthe supplies for maintenance, infusion supplies, and Milrinone lactate injection. The Plan denied your request. The Plan saysOriginal Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe supplies for maintenance of non-insulin drug infusion catheter, infusion supplies, and Milrinone lactate injection provided from March 26, 2020, to April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. 
The Plan says that prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 physician services provided by an out of network
 (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist office visit provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist office visit. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that there are in-network providers available for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 specialist office visit provided by 
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care from May 10, 2020, 
through June 2, 2020. 
 
You asked the Plan to pay for SNF care. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says the beneficiary does not meet the criteria for SNF admission, in accordance 
with the Medicare Guideline for Skilled Nursing Facility level of care/services. The member did not have any 
skilled level needs noted; and the member did not receive/require daily MD management, daily skilled level 
nursing care, or skilled therapy during the requested DOS. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care 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 pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy 
service needs and the beneficiary does not require skilled nursing or therapy services on a daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care from May 10, 2020, through June 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 17, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is a 65-year-old female with a past medical history of breast cancer, right-sided 
lymphedema, hypertension, asthma, and eczema. She was diagnosed with secondary metastatic malignant 
neoplasm of the skin with a right breast primary tumor site. A request for Caris MI Profile and Next Generation 
sequencing (NGS) testing was made. This tumor biomarker analysis matches potential therapies to patient-
specific biomarker information. Upon review of the available supportive evidence for using the Caris MI 
Profile NGS testing, there was insufficient quality evidence showing that this test led to significant improved 
outcomes. Therefore, it will be considered not medically necessary at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on March 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medicallynecessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 required stand-by assistance to walk 200 feet times two with a front wheeled walker. The enrollee required minimal assistance for transfers. The enrollee required supervision to minimal assistance for activities of daily living. Thedocumentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. The enrollee's 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided. 
 
You asked the Plan to pay for anesthesia services. You say that the claim was timely. The Plan denied your 
request. The Plan says that this is a duplicate claim that was already paid. 
 
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. There is no documentation on whether the recoupment was made. The claim 
appears to be a corrected claim which was not addressed.  Therefore, we decided that the Plan has to pay for 
anesthesia services provided.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care 
 
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the medical services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided  by an out of network provider. 
 
You asked the Plan to pay for the therapy services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
 
 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the therapy services provided by an 
out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and complete series 
of intraoral x-rays provided on June 11, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays. 
You say that the Plan's sales agent confirmed that this provider was in network before you signed up for this 
plan. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan 
also says that you were advised that this provider was not in network with the 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, prophylaxis, and complete series of intraoral x-rays provided on June 11, 2020 by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation care provided 
February 14, 2020 to February 28, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that you were told it 
would be $275 a day for the first 5 days after surgery in the hospital, and after at least a 3 day hospital stay the 
rehab would be no charge. So you are appealing that you owe $1,375. The Plan denied your request. The Plan 
says the claim processed with the correct copayment applied per the plan's Evidence of Coverage.  
 
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 $275 
copayment per day for days 1-5 for Medicare covered inpatient hospital care.  
 
You have been asked to pay $1,375 ($275 x 5 days = $1,375) for the inpatient rehabilitation care. The inpatient 
rehabilitation care falls within the Inpatient hospital care 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 copayment for the inpatient rehabilitation care provided February 14, 2020 to February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact fitting you had on July 21, 2020. 
 
You asked the Plan to pay for the services. You say that you did not have a contact fitting. The Plan denied 
your request. The Plan says this is not a covered benefit. 
 
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. The Plan does not covered contact fittings. 
 
We looked at the file and the Plan's rules. The Plan contract clearly states that contact fitting fees are not 
covered. Based on this information, we decided that the Plan's rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the contact fitting you had on July 21, 2020.
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 cannot get out of bed and has difficulty 
caring for himself. The Plan denied your request. The Plan says the denial of authorization for IRF service is 
correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's needs can be met at a lower level of care such as skilled nursing facility. 
 
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 fora bone density scan (77080) provided June 29, 2020.You asked the Plan to pay forthe bone density scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.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 77080 is not supported in the medical record. Specifically, CPT code 77080 was already paid on the date of service. The documentation does not support the procedure being performed twice. Based on this information, we decided that Medicare rules for coverage of the bone density scan have not been met.Therefore, we decided that the Plan does not have to pay fora bone density scan (77080) provided June 29, 2020.