Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (99199, S9122) provided May 7, 2020 
to May 9, 2020. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered. You had 
to bring the enrollee home with home health services due to COVID-19 affecting the Nursing Facility she 
resided at. The Plan denied your request. The Plan says the provider of the Home Health services is not a 
Medicare participating provider. 
 
The Plan must follow Medicare rules. Medicare 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.  
 
We looked at the file and Medicare rules. The provider that rendered the services is not Medicare certified. 
There were Medicare participating providers available to provide the services at issue. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (99199, S9122) provided 
May 7, 2020 to May 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand-orthosis provided on February 
20, 2020. 
 
You asked the Plan to pay for orthosis. You say that you are appealing with records to confirm medical 
necessity. The Plan denied your request. The Plan says the denial of payment for this item is correct, because 
the consultation for this item was made by telemedicine which is not covered by Medicare for the enrollee's 
geographic area. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract.  
 
 
 
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-elbow-wrist-
hand-orthosis provided on February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Keytruda. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of non-small 
cell lung cancer. Review of submitted documentation does not support expression PD-L1. Review of Medicare 
approved compendia supports the use of Keytruda for patients with PD-L1 expression greater than/ 1%. 
Without the support of the compendia, medical necessity cannot be determined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says all services 
obtained from an out-of-network provider will not be covered unless there is prior authorization for the 
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 did not pre-approve the 
laboratory services. 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 laboratory services provided on June 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on August 31, 2018. 
 
You asked the Plan to pay for home health visit. You say that you were told this claim would be paid. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because this claim did not 
include the required Q code designating the location where service was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that home health agencies must report where home 
health services were provided by billing codes Q5001, Q5002, or Q5009 as applicable along with the first visit 
reported on a claim.  
 
We looked at the file and Medicare rules. This claim was not billed with the applicable Q code designative the 
location where service was provided. Based on this information, we decided that Medicare rules for coverage 
of home health visit have not been met. Therefore, we decided that the Plan does not have to pay for a home 
health visit provided on August 31, 2018.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 7, 2019. 
 
You asked the Plan to pay for laboratory services. 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. 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 for laboratory services provided on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3D radiology rendering and interpretation (76377) provided 
May 1, 2020. 
 
You asked the Plan to pay for the 3D radiology rendering and interpretation. You say that the service was 
medically necessary. The Plan denied your request. The Plan says this CPT code is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.  
  
In this case, we have confirmed that the 3D radiology rendering and interpretation has a bundled relationship 
with code 70553 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for 3D radiology rendering and interpretation (76377) provided May 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic screening testing provided on September 4, 2019. 
 
You asked the Plan to pay for genetic test. You say that the enrollee's treating physician ordered this testing as 
a fully validated test that demonstrates clinical utility. The Plan denied your request. The Plan says the denial 
of payment for this service is correct, because this test is not covered for screening purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, genetic test, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
genetic screening testing provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine cultures by PCR provided on October 9, 2019. 
 
You asked the Plan to pay for the PCR urine cultures. You say that this testing was necessary and should be 
covered. The Plan denied your request. The Plan says the blood cultures by PCR were paid as these are 
considered reasonable in this elderly patient. However, the role for urine cultures by PCR is not established 
 
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 PCR urine cultures. Our reviewer says 
that the testing provided is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 102-year-old woman who was noted to have erythema of her face, neck and 
arms. Vital signs were unremarkable. An ulcerated lesion was noted on the bridge of the nose. The enrollee was 
assessed to have a cutaneous drug reaction. A lateral left foot wound was stable. Urine PCR testing has not 
been shown to be useful for the management of the enrollee's condition. Testing which has no proven relation 
to the management of a medical diagnosis of disease for the health of an enrollee is not a covered Medicare 
benefit. 
 
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 PCR urine cultures have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine cultures by PCR provided on October 9, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdomen, CT of the abdomen and 
pelvis, laboratory services, and ED visit and services provided on May 23, 2020. 
 
You asked the Plan to pay for the ultrasound, CT, laboratory services, and ED services. You say that the 
enrollee was no longer in hospice. The Plan denied your request. The Plan says the enrollee was enrolled in an 
active hospice election period from March 20, 2020, through May 18, 2020. The Plan also says that since the 
hospice was revoked mid-month, the Hospice Program would continue to pay for services until the first of the 
following month (June 1, 2020). 
 
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 May 18, 2020. 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 ultrasound of the 
abdomen, CT of the abdomen and pelvis, laboratory services, and ED visit and services provided on May 23, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
March 23, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
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 $45 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office.  
 
You have been asked to pay a $45 copayment for the telehealth specialist office visit provided. 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 office visit (99213) provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 30, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on October 7, 2019, October 24, 
2019, and November 7, 2019. 
 
You asked the Plan to pay for the dental services. You say that you want the bill covered under medically 
necessary dental care. The Plan denied your request. The Plan says your annual dental maximum has been paid. 
 
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. The Plan paid $1,000 toward dental services provided on March 21, 2019, April 9, 2019, May 16, 2019 
and May 24, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 
the dental services provided on October 7, 2019, October 24, 2019, and November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on February 14, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the beneficiary was already a patient in the 
hospital when services were rendered. The Plan denied your request. The Plan says prior authorization must be 
obtained for non-emergent services 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 nursing facility care (99309) provided on 
February 14, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 4, 2019, to July 10, 
2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that it is felt that inpatient payment is 
appropriate in this case. The Plan denied your request. The Plan says that the enrollee's condition did not 
require inpatient care. Observation would have been sufficient. 
 
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 the enrollee was a then 75-year old male who resides at a nursing home. He was admitted to 
the hospital from 7/5/2019 to 7/10/2019 after a fall. He has a medical history of atrial 
fibrillation, Alzheimer's dementia, hypertension, congestive heart failure, diabetes, and stroke. The member 
fell at home when trying to stand up from a seated position. The member did not report any injuries in the 
emergency department. At the hospital, the member underwent chest x-ray, computed tomography (CT) of the 
head and cervical spine, and had labs drawn. No findings on imaging. He was admitted for further monitoring. 
He was found to have a urinary tract infection and started on intravenous Ceftriaxone. His condition stabilized 
and improved and he was discharged back to the nursing facility when considered medically stable on 
7/10/2019. The review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the patient'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 the acute inpatient hospital care provided from July 4, 2019, to July 10, 2019.  
 
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 subsequent nursing facility care provided on May 19, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 subsequent nursing facility care provided on May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion equipment (A4222) provided October 8, 2019. 
 
You asked the Plan to pay for the infusion equipment. You say that the billed items were medically necessary. 
The Plan denied your request. The Plan says payment for the infusion equipment is included in payment for the 
infusion services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare's payment for the administration of 
the drug or biological billed to the MAC will also include payment for equipment used in furnishing the 
service. Equipment, such as an external infusion pump used to begin administration of the drug or biological 
that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for 
a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit. This code cannot be paid 
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, 
we decided that the Plan does not have to pay for infusion equipment (A4222) provided October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM system. You say that the item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
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 Freestyle Libre CGM system. Our 
reviewer says that the item is not necessary. Our physician reviewer found the plan calls for coverage of a 
CGM if the enrollee is taking insulin, amongst other things. This enrollee is not taking insulin and there is no 
reason given why a hand held glucometer cannot be used to provide adequate blood glucose data or why a libre 
CGM is needed instead of the glucometer. 
 
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 Freestyle Libre CGM system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure (D1999) provided on 
June 16, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure (D1999). You say that you shouldn't be 
responsible for the $10. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
unspecified preventive procedure (D1999) provided on June 16, 2020.