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

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 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. The enrollee 
was admitted for a fall with no acute injuries. Medical problems are stable. 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. The record does support a 
need for physical and occupational therapy but there is no need for an intensive rehabilitation program. There is 
not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs Perjeta (J9306), Trastuzumab (J9355), Docetaxel 
(J9171), Carboplatin (J9045), Palonosetron (J2469), Dexamethasone (J1100), and Filgrastim-sndz (Zarxio) 
(Q5101). 
 
You asked the Plan to pre-approve drugs Perjeta (J9306), Trastuzumab (J9355), Docetaxel (J9171), 
Carboplatin (J9045), Palonosetron (J2469), Dexamethasone (J1100), Filgrastim-sndz (Zarxio) (Q5101). You 
say that the requested drugs are medically necessary. The Plan denied your request. The Plan says the requested 
drugs are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drugs Perjeta (J9306), Trastuzumab 
(J9355), Docetaxel (J9171), Carboplatin (J9045), Palonosetron (J2469), Dexamethasone (J1100), Filgrastim-
sndz (Zarxio) (Q5101). Our reviewer says that the requested drugs are not medically necessary. Our physician 
reviewer found this enrollee has a small node negative stage I breast cancer. This enrollee does not have a high 
risk of recurrence and pertuzumab is not indicated. Many consider standard of care to be combination of 
paclitaxel and trastuzumab per NCCN Guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drugs Perjeta (J9306), Trastuzumab (J9355), Docetaxel (J9171), Carboplatin 
(J9045), Palonosetron (J2469), Dexamethasone (J1100), Filgrastim-sndz (Zarxio) (Q5101) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve drugs Perjeta (J9306), Trastuzumab (J9355), 
Docetaxel (J9171), Carboplatin (J9045), Palonosetron (J2469), Dexamethasone (J1100), and Filgrastim-sndz 
(Zarxio) (Q5101).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 7, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order for these tests and some of the tests billed to not match the sample type 
collected for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 14, 2020. 
 
You asked the Plan to pay for the lab 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 documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME purchased April 10, 2020 from a non-Medicare 
provider. 
 
You asked the Plan to pay for the DME. You say that your medical provider does not carry your brand and 
model of supplies any longer so your ordered from this provider. You state a Plan representative told you that 
by submitting a reimbursement request form you can be reimbursed. The Plan denied your request. The Plan 
says this provider is not certified for Medicare. 
 
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. 
 
Review of the file show that you purchased DME on April 10, 2020 from a non-Medicare provider. The rules 
say that to receive payment for covered Medicare items or services from either Medicare (in the case of an 
assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be 
enrolled in the Medicare program. 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 DME purchased April 10, 
2020 from a non-Medicare provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesiology services provided on January 18, 2019. 
 
You asked the Plan to pay for the anesthesiology services. You say that the provider never filed the claim. The 
Plan denied your request. The Plan says the claim is untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesiology services was not filed until April 29, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the anesthesiology services provided on January 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 5, 2020. 
 
You asked the Plan to pay for the lab 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 documentation of the ordering 
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve a BiPAP device and humidifier for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has been non-compliant with the device.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the compliance report for 6/30/20 shows usage at least four hours for 70% of the nights, which meets Medicare criteria. 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 services have been met. Therefore, we decided that the Plan has to pre-approve a BiPAP device and humidifier for the enrollee.
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided from December 18, 2019 to 
December 30, 2019. 
 
You asked the Plan to pay for the diagnostic imaging. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 18, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the radiology 
services provided from December 18, 2019 to December 30, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a lower extremity CT Scan (73700) provided on April 17, 2020. 
 
You asked the Plan to pay for the lower extremity CT Scan. You say that you would like reconsideration 
because the member had multiple exams on the same date of service. The Plan denied your request. The Plan 
says that the submitted documentation supports 1 unit of 73700-26,which was previously approved/paid. 
 
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 73700 is computed tomography, lower extremity; without contrast material. 
 
We find that CPT code 73700 is supported in the record. Specifically, the documentation submitted indicates 
that multiple CT Scans were rendered on the billed date of service. Based on this information, we decided that 
Medicare rules for coverage of the lower extremity CT Scan have been met. Therefore, we decided that the 
Plan has to pay for a lower extremity CT Scan (73700) provided on April 17, 2020.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 
16, 2019. 
 
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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 81057: Carbamepazine; free 
 
CPT 80159: Clozapine 
 
CPT 80162: Digoxin; total 
 
CPT 80173: Haloperidol 
 
CPT 80177: Levetiracetam 
 
CPT 80201: Topiramate 
 
HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed 
 
CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or 
procedures, by instrument chemistry and analyzers (e.g.,  utilizing immunoassay [EIA, ELISA, EMIT, FPIA, 
IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without 
chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes 
sample validation when performed, per date of service 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found urine 
sampling would not screen for the majority of the substances tested. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 18, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. The testing at issue is performed on a blood specimen. The documentation does not show that a blood 
sample was provided from the enrollee. Based on this information, we decided that Medicare rules for coverage 
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on 
December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 9, 2020. 
 
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 documentation submitted is missing a CLIA-required modifier; therefore, the billed services 
cannot be verified. 
 
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 the denied codes is: 
 
CPT 80061: 
 
Lipid panel 
 
CPT 80053: 
 
Comprehensive metabolic panel 
 
CPT 81003: 
 
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 
protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 
 
CPT 84443: 
 
Thyroid stimulating hormone (TSH) 
 
CPT 85025: 
 
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential 
WBC count 
 
We find that the denied CPT codes are not supported in the medical record. Specifically, these codes require a 
CLIA modifier. 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 lab services provided to the enrollee 
on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the dental services provided on April 24, 2020. 
 
You asked the Plan to pay more for the dental services. You say that your choices for a dentist were limited to 
this practice. You say that the facility should be paid. The Plan denied your request. The Plan says the claim 
was reprocessed as a one-time exception to apply the in-network benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have an annual maximum of 
$1,000. Although the provider has opted out of Medicare, the Plan has made a one-time exception to pay for 
your covered dental services. Since the Plan has paid your $1,000 annual maximum, the remaining amount is 
your responsibility. Therefore, we decided that the Plan does not have to pay more for the dental services 
provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on February 17, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dialysis services provided from March 1, 2019 to March 31, 
2019. 
 
You asked the Plan to pay for the dialysis services (90999). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says medical records were requested but not received. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There are no clinical records supporting this service. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Based on 
this information, we decided that Medicare rules for coverage of the dialysis services (90999) have not been 
met. Therefore, we decided that the Plan does not have to pay for dialysis services provided from March 1, 
2019 to March 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 20, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 G0483 is not supported in the medical record. There were insufficient records that show 
the tests were needed to identify specific substances that were inadequately detected by a presumptive drug 
test. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed 
medications or illicit substances. The records provided do not document concerns based on clinical review and 
judgement. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. This testing is performed on blood samples. The documentation provided shows that only a urine 
sample was provided for the enrollee. Based on this information, we decided that Medicare rules for coverage 
of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on December 20, 2019.