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 March 18, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is on oxygen, she is debilitated since 
heart surgery and you believe she will benefit more from P/T and O/T at an ARU level. You say that she also 
needs vital signs monitored and wound checks for her chest incision. The Plan denied your request. The Plan 
says an inpatient rehabilitation facility admission is 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 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 that the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, skin care, and daily therapy can be provided at a SNF. The enrollee is mostly MODERATE to 
MAX assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy 
may be more appropriate.  It is not clear that the enrollee would be able to fully benefit and/or participate in an 
IRF 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-approve IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TDAP vaccine provided on May 29, 2020. 
 
You asked the Plan to pay for preventative vaccines under Medicare Part B.. You say that it had been five years 
since your last vaccine, and you needed it updated. The Plan denied your request. The Plan says this vaccine is 
not covered under Medicare Part B. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide preventative 
vaccines under Medicare Part B. The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to preventative 
vaccines under Medicare Part B. This vaccine was preventative. Therefore, we decided that the Plan does not 
have to pay for the TDAP vaccine provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 13, 2020 and January 27, 2020. 
 
You asked the Plan to pay for these claims. You say that these claims should be paid. The Plan denied your 
request. The Plan says the Plan 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 out of network physician services provided to the enrollee on 
January 13, 2020 and January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 18, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 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 is missing the main code and identifier 
required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the 
enrollee on June 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda/Paraplatin/Gemcitabine for the enrollee. 
 
You asked the Plan to pre-approve the regimen. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this combination is helpful for treatment of this 
health problem. 
 
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 the regimen. Our reviewer says that the 
requested regimen is not medically reasonable or necessary. Our physician reviewer found the he combination 
of carboplatin, gemcitabine, and pembrolizumab is not considered a standard of care for first line treatment of 
metastatic non-squamous cell non-small cell lung cancer. This use is not FDA approved, supported by major 
drug compendia, the NCCN Guidelines, or the medical literature. Prior studies showed inferior to combination 
of carboplatin and pemetrexed and combination with pembrolizumab has not been established. The service is 
not reasonable or 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 the regimen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda/Paraplatin/Gemcitabine for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided on January 3, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because the 
authorization dates were unclear. The Plan denied your request. The Plan says the initial approval was for 20 
days effective December 14, 2019. 
 
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 the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found as of January 3, 2020 the member 
required custodial services. 
 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF services provided on January 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the patient has had prior therapy for this condition and 
indicates it has helped temporarily. The records do not indicate she requires the ongoing unique skills of a 
professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively 
be performed only by a therapist, or under the supervision of a therapist. The patient has had prior therapy since 
early June and should be able to transition to home exercises. The requested services are not  part of a 
maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on July 31, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on July 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for coverage of an IRF admission. 
 
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 that the enrollee is currently not medically stable with complex medical issues that 
require monitoring by an acute treating medical team. While he may benefit from continuing physical and 
occupational therapy, there is no evidence of a need for an intensive therapy program with therapy three hours 
per day when he cannot tolerate therapies. The enrollee does not meet the Medicare coverage criteria for 
admission to an inpatient rehabilitation facility based on medical complexity and the inability to tolerate 
therapies.  
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department evaluation and management (EM) services 
provided on November 7, 2019 billed with code 99285-57. 
 
You asked the Plan to pay for the EM services. You say that this was correctly billed for the EM services 
necessary to allow for the decision to perform surgery. The Plan denied your request. The Plan says that only if 
the documentation shows services separate and distinct from the dislocation treatment may an 
E&M code be billed with CPT code 23650. 
 
The Plan must follow Medicare rules. Medicare rules say that evaluation and management services on the day 
before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are 
not included in the global surgery payment for the major surgery. 
 
Code 23650 is a major surgery code with a 90-day global period. As such, EM services billed on the same date 
are payable when modifier -57 is used. Therefore, we decided that the Plan has to pay for the emergency 
department evaluation and management (EM) services provided on November 7, 2019 billed with code 99285-
57.  
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided.
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says that an 
observation level of care would have been appropriate. 
 
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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
April 14, 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 out of network physician services provided to the enrollee on 
April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 6, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 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 is missing the main code and identifier 
required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the 
enrollee on April 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health treatment. 
 
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient mental health treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the 
criteria for continued acute inpatient mental health treatment for the dates in question of August 21, 2020 
forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or 
visual hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety 
of herself or others. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 19, 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 Plan says this is an administrative determination for coding and is not based on 
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use 
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 
 
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 is missing the main code 
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of 
this claim have not been met. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on March 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 32 psychotherapy visits (90837) and 32 office visits 
(99215) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve 32 psychotherapy visits and 32 office visits to be provided by an OON 
provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-
network providers that are able to provide these services. Therefore, coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
32 psychotherapy visits (90837) and 32 office visits (99215) to be provided by an out of network (OON) 
provider.