Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Telehealth Transitional Care Management provided on 
December 31, 2019. 
 
You asked the Plan to pay for the telehealth service. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the claim was not submitted with the correct POS 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 99496 is not payable as submitted. Specifically, the POS code 02 for telehealth, is not 
on the claim. Based on this information, we decided that Medicare rules for coverage of the telehealth service 
have not been met. Therefore, we decided that the Plan does not have to pay for Telehealth Transitional Care 
Management provided on December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 5, 2020. 
 
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 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 test at issue in this appeal, a cardiovascular risk assessment, 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 laboratory services rendered on May 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on March 12, 2020, by an out 
of network provider. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says you did not request prior authorization for the non-urgent services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the therapy services provided on March 12, 2020, by an out of network 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular genetic testing panel provided on March 16, 
2020. 
 
You asked the Plan to pay for the testing services. You say that the records support the need of the procedures 
done. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed. 
 
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 for screening purposes. The file contains insufficient medical 
records to show that the results of the testing would be used to determine a specific treatment strategy. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the molecular genetic testing panel provided on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foam dressing, wound cover, sterile, without adhesive 
border, each dressing (A6209). 
 
You asked the Plan to pre-approve the foam dressing. You say that you have pressure points on your knees that 
have resulted in weeping and you have to keep them covered or they erupt and leak. The Plan denied your 
request. The Plan says the Medicare criteria for coverage of surgical dressings was not 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 the foam dressing. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male with pressure point blisters on the legs which were protected by 
foam dressing to prevent disruption. However, the criteria require the wound to be full thickness and have 
moderate to heavy exudate, neither of which describe the superficial wounds noted in the provided records. 
Therefore, the criteria for foam dressing is not met. 
 
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 foam dressing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve foam dressing, wound cover, sterile, without adhesive border, each dressing (A6209).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95819 and 
the digital analysis of electroencephalogram (EEG) services coded 95957 provided on August 20, 2019. 
 
You asked the Plan to pay for the electroencephalogram (EEG) services and the digital analysis of 
electroencephalogram (EEG) services. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 95819 and 95957 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of electroencephalogram (EEG); including recording 
awake and asleep; therefore, code 95819 cannot be verified. The documentation submitted did not include 
documentation of digitally analyzed spike; therefore, code 95957 cannot be verified. Additionally, it is not 
appropriate to report 95957 for source localization when there are no spikes to analyze. Based on this 
information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) services and the 
digital analysis of electroencephalogram (EEG) services have not been met. Therefore, we decided that the 
Plan does not have to pay for the electroencephalogram (EEG) services coded 95819 and the digital analysis of 
electroencephalogram (EEG) services coded 95957 provided on August 20, 2019.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial. They did not provide any medical 
records for the Qualified Independent Contractor to review. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF)  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided requiring admission to a LTACH. The enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The review has determined that the enrollee does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis 
and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on January 10, 2020. 
 
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 procedure codes 95907 and 95885 are not supported. 
 
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 95907 is nerve conduction studies; 1-2 studies. The 
definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when 
performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in 
addition to code for primary procedure). 
 
We find that CPT codes 95907 and 95885 are not supported in the medical record. Specifically, the technical 
report does not include documentation of 1-2 nerve conduction studies to support code 95907. The technical 
report does not include documentation of limited needle electromyography to support code 95885. 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 testing services rendered on January 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic 
x-ray (D0330) provided on September 23, 2019. 
 
You asked the Plan to pay for the dental services. You say that you received a notification that your dental 
claim was approved. You say that the decision was then reversed because the provider has opted out of 
Medicare. You also say that you were not aware that the dentist had opted out. The Plan denied your request. 
The Plan says the provider opted out of Medicare as of July 17, 2015. The Plan says payment cannot be made 
to providers that have opted out of Medicare. The Plan also says there are in network providers that would be 
able to provide these services. 
 
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 has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular testing provided on May 5, 
2020. 
 
You asked the Plan to pay for the testing services. You say that the testing will determine whether the profile is 
the result of a gene mutation. The Plan denied your request. The Plan says comprehensive genomic profile 
testing is limited to one test per specimen. 
 
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 for screening purposes. Medicare does not cover this testing for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular 
testing provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a knee arthroplasty (27447), PT evaluation 
(97162), and OT evaluation (97165) received from May 13 to May 20, 2020. 
 
You asked the Plan to waive the coinsurance for a knee arthroplasty, PT evaluation, and OT evaluation. You 
say that you should not be held responsible for these charges. The Plan denied your request. The Plan says the 
correct coinsurance was applied. 
 
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 20% 
coinsurance for each Medicare-covered outpatient hospital facility visit and each Medicare-covered outpatient 
rehabilitation service visit.  
 
You have been asked to pay 2,190.21, or 20% coinsurance of the Plan-allowed amount of $10,951.03, for a 
knee arthroplasty. You have also been asked to pay $16.49, or 20% coinsurance of the Plan-allowed amount of 
$82.43, for a PT evaluation and $17.46, or 20% of the Plan-allowed amount of $87.29, for an OT evaluation. A 
knee arthroplasty falls within the "Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers" benefit category. A PT evaluation and OT evaluation fall within the 
"Outpatient rehabilitation services" 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 coinsurance for a knee arthroplasty (27447), PT evaluation 
(97162), and OT evaluation (97165) received from May 13 to May 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compounded drug coded J7999 provided on August 28, 
2019. 
 
You asked the Plan to pay for the compounded drug. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 J7999 is compounded drug, not otherwise classified. 
 
We find that CPT code J7999 is not supported in the medical record. Specifically, the submitted medical 
records do not support the units billed. 225 units of this code were billed. The plan approved and paid one unit. 
Only one unit is appropriate to bill for this code. On another claim line, 5 units of this code was billed. The 
submitted medical records do not support 5 additional units billed. Based on this information, we decided that 
Medicare rules for coverage of the compounded drug have not been met. Therefore, we decided that the Plan 
does not have to pay for the compounded drug coded J7999 provided on August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus ointment. 
 
You asked the Plan to pre-approve Tacrolimus ointment. You say that this is necessary to maintain the 
enrollee's skin integrity. The Plan denied your request. The Plan says coverage of this medication is the 
responsibility of the enrollee's prescription drug plan. 
 
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 Tacrolimus ointment.  
 
Benefits for Tacrolimus ointment 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 outpatient services provided on March 23, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the 
outpatient services were distinct from the inpatient admission. The Plan denied your request. The Plan says 
these services are included in the hospitals contract rate per Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic services and non-diagnostic 
services that are related to an inpatient admission during the 3 calendar days immediately preceding the date of 
admission are required to be included on the Part A bill for the inpatient stay.
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the record does not include a condition 
code to indicate that the outpatient services were unrelated to the inpatient stay. Payment for these services is 
included in the Part A bill for the inpatient stay. Therefore, we decided that the Plan does not have to pay for 
outpatient services provided on March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of an LTACH over an acute 
hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be improving, but requires additional acute care services to further stabilize which is likely to take 
24 days or less based on recent notes. The patient does not require services at the LTACH that are not already 
available at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tacrolimus cap 1mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication falls under Part D benefits. 
 
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 Tacrolimus cap 1mg for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is the level of care needed for the enrollee 
to regain maximum function. The Plan denied your request. The Plan says the guidelines for coverage of IRF 
care have not been met. The Plan says that the enrollee can safely receive the services needed in another 
setting. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for dyspnea and edema. He was treated for pneumonia and had surgery for spinal abscess 
associated with recent spinal surgery.  The enrollee's medical problems are stable and 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. While the medical 
record does document a need for physical and occupational therapy, it does not document a need for an 
intensive rehabilitation program. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.