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

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on January 14, 2020 and 
billed under codes 81225, 81226, 81227, 81230, 81231, 81355 and 81479. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee had cardiovascular risk assessment testing on January 14, 2020.  Medicare 
denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic 
patients with suspected or documented cardiovascular disease. Based on the medical records, Medicare 
coverage criteria were not met.  
 
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 records provided do not support 
the services billed or show the enrollee met the required coverage criteria are the time of testing. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on January 14, 2020 and 
billed under codes 81225, 81226, 81227, 81230, 81231, 81355 and 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on February 25, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 lab services provided to the 
enrollee on February 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services. 
 
You asked the Plan to pay for IRF care. You say that you would like reconsideration because the IRF care was 
medically necessary. The Plan denied your request. The Plan says the IRF care was not medically necessary. 
 
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 pay for 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 member's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a 
reasonable expectation that this member 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 pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and neurofeedback provided from June 4, 
2020, to June 25, 2020.  
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says this provider is not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who in not a Medicare eligible provider.  
This provider is not a Medicare eligible provider and is not eligible to accept Medicare payment. Therefore, we 
decided that the Plan does not have to pay for physician services and neurofeedback provided from June 4, 
2020, to June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on November 20, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing is not covered. 
 
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, definitive drug testing, 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 the drug testing rendered on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 165 units of anesthesia (00790) provided on March 27, 2020. 
 
You asked the Plan to pay for 165 units of anesthesia. You say that this is clearly shown in the records. The 
Plan denied your request. The Plan says only 143 units are indicated in the record. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
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 165 units of anesthesia Our reviewer says 
that the billed units are not supported. Our physician reviewer found the number of units performed is unable to 
be determined due to no exact anesthesia end time being documented in the records. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 165 units of anesthesia have not been met. Therefore, we decided that the Plan 
does not have to pay for 165 units of anesthesia (00790) provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 16, 2020.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.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 substitutefor 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 fora lumbar-sacral orthosis (L0648) provided to the enrollee on June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 24, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing was ordered as a screening and is not covered by Medicare. 
 
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 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 lab services provided to the enrollee on March 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not 
covered. 
 
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 testing at issue in this appeal 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 the lab services 
provided.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a percutaneous left atrial appendage closure (Watchman Device) 
(93355, 33340). 
 
You asked the Plan to pre-approve a percutaneous left atrial appendage closure. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the requirements for the preoperative evaluation by 
a multi-disciplinary team have not been met. 
 
{The Plan follows Medicare rules. Medicare rules say that LAAC devices are covered when the device has 
received Food and Drug Administration (FDA) Premarket Approval (PMA) for that device's FDA-approved 
indication and meet all of the conditions specified 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 a percutaneous left atrial appendage 
closure. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the 
patient has recurrent documented symptomatic PAF and he cannot take long-term anti-coagulation owing to 
recurrent iron deficiency anemia which was symptomatic and required transfusion. His CHA2DS2VASc score 
is 3 and he should be anti-coagulated based on this to decrease his risk of embolic stroke. As he has had 
recurrent anemia on anti-coagulation which cannot be rectified with GI interventions, he would meet clinical 
criteria for a left atrial occluder device based on published guidelines. The requested service is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a percutaneous left atrial appendage closure have been met. Therefore, we 
decided that the Plan has to pre-approve a percutaneous left atrial appendage closure (Watchman Device) 
(93355, 33340).  
 
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 the hereditary cancer genetic testing provided on April 10, 
2019. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the clinical 
information did not indicate the enrollee was having current symptoms, or that treatments would be affected by 
testing. 
 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
hereditary cancer genetic testing provided on April 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xeljanz. 
 
You asked the Plan to pre-approve Xeljanz. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 pre-approve Xeljanz.  
 
Benefits for Xeljanz 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 home infusion therapy (S9328) provided on May 11, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that this has previously been covered. The Plan 
denied your request. The Plan says this is not a payable 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. 
 
We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status 
indicator of I. Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on May 
11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services provided on May 18, 
2020. 
 
You asked the Plan to waive the copayment for physician services. You say that you thought you would not be 
charged a copayment for a telehealth visit. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $10 
copayment for primary care provider visits.  
 
The medical records show that you received physician services on May 18, 2020. Therefore, you are 
responsible to pay the $10 copayment.  
 
You have been asked to pay a $10 copayment for physician services. Physician services fall within the 
physician/practitioner services, including doctors office visits 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 physician services provided on May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on June 3, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the provider billed code A0429 with QL modifier. The records indicate the enrollee was 
pronounced dead after the ambulance was called. Medicare Guidelines state providers should report the A0428 
(BLS) HCPCS code with the QL modifier when the enrollee is pronounced dead after the ambulance is called. 
Medicare criteria were not met.  
 
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 claim submitted has an 
inappropriate code based on the enrollee's status at the time of transport. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided to the enrollee on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the established patient office or other 
outpatient visit (99213) provided on August 10, 2020. 
 
You asked the Plan to waive the copayment for the established patient office or other outpatient visit. You say 
that you disagree with the copayment as charged and feel like there should be a reduction. The Plan denied 
your request. The Plan says the copayment applied correctly in this case. 
 
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 $40 
copayment for telehealth services for specialty care visit.  
 
You have been asked to pay a $40 copayment for the established patient office or other outpatient visit. The 
service provided falls within the telehealth services for specialty care visit 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 established patient office or other outpatient visit (99213) 
provided on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waivethe cost share for vision services provided on June 25, 2020.You asked the Plan to waivethis cost share. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says per the contract there is a $40 copayment for vision care, per visit to an ophthalmologist or optometrist for Medicare-coveredvision care. The Plan states that a particular provider should be used. The Plan states on June 25, 2020 you had a refraction visit (92015) with a $50.00 charge. As this is only a benefit when obtained from a particular provider, no payment was made on this service. You also had a Medicare-covered eye exam (92014) and scanning computerized ophthalmic diagnostic imaging (92133) with a copayment of $40.00. A total cost of $90.00 was correctly applied to the services obtained on this visit.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 covers these services when a specific provider is used. You did not use the Plans preferred provided for these services. Therefore, we decided that the Plan does not have to waivethe cost share for vision services provided on June 25, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on July 26, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was billed with an 812 TOB with no room and board lines, deeming this 
claim non-payable. Therefore, claim the service was denied as inappropriately billed.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, the claim submitted does not have an 
appropriate TOB code. Medicare rules for coverage of this service have not been met. Therefore, we decided 
that the Plan does not have to pay for medical services provided to the enrollee on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. 
 Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on March 30, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by you on March 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transportation (A0431, A0436) provided April 
7, 2020. 
 
You asked the Plan to pay for the air ambulance transportation. You say that the air transport services were 
medically necessary. The Plan denied your request. The Plan says the patient was stable for ground transport. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance transportation. Our 
reviewer says that air transport was not medically necessary. Our physician reviewer found the documentation 
does not support the level of instability that would necessitate air travel. 
 
 
 
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 air ambulance transportation have not been met. Therefore, we decided that 
the Plan does not have to pay for air ambulance transportation (A0431, A0436) provided April 7, 2020.