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

 
We decided that the Plan does not have to pay for hyperbaric oxygen therapy (CPT 99183) provided to the 
enrollee on June 8, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted documentation supports one unit of CPT 99183, which was previously approved 
and paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99183 is "Physician or other qualified health care 
professional attendance and supervision of hyperbaric oxygen therapy, per session." 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the 
documentation includes a duplicate session of hyperbaric oxygen therapy performed on June 8, 2020, no other 
documentation was submitted to support additional sessions. The service should be billed as one unit per 
session.  Therefore, additional units cannot be confirmed as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for hyperbaric oxygen therapy (CPT 99183) provided to the enrollee on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee 
on May 24. 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that a comprehensive lung disorder respiratory panel was medically 
reasonable and necessary for the enrollee in this case. It has not been demonstrated that the testing would 
impact the management and outcome of this enrollee. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic screening testing provided to the enrollee on May 24. 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccine for tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) provided to the enrollee on October 2, 2020. 
 
You asked the Plan to pay for the vaccines. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccines. 
Therefore, we decided that the Plan does not have to pay for the vaccine for tetanus, diphtheria toxoids and 
acellular pertussis vaccine (Tdap) provided to the enrollee on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and a panoramic 
radiographic image (D0330) provided on October 15, 2020. 
 
You asked the Plan to pay for a comprehensive oral evaluation and a panoramic radiographic image. You say 
that you were unaware of coverage restrictions. The Plan denied your request. The Plan says the services are a 
covered benefit, but you have exceeded the frequency limit of one every three plan years. 
 
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.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a comprehensive oral evaluation and a panoramic radiographic image have not 
been met. Specifically, the record shows that you had exceeded the frequency limit prior to this service on May 
16, 2018. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), and a panoramic radiographic image (D0330) provided on October 15, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the member requires skilled care due to poor 
endurance and being high risk for falls. The Plan denied your request. The Plan says that the member can have 
the care they need at home with home health care or at an alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a 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 care can be provided in the current inpatient 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. Our 
physician reviewer found the enrollee appears to be more stable and only requires short-term additional acute 
care services to further stabilize that can safely be received at the current facility until an appropriate longer-
term location and level of care may be determined. The enrollee does not require services at the LTACH that 
are not already available and covered at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Therefore, this request for 
LTACH will be considered not medically necessary at this time. Transfer may be considered soon when 
appropriate. 
 
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 LTACH 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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 22, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
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 September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (HCPCS Q0092 and HCPCS R0070) 
provided to the enrollee on October 2, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service is inappropriate for this procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
HCPCS Q0092: 
 
Set-up portable x-ray equipment 
 
HCPCS R0070: 
 
Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or 
location, one patient seen 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found these 
services were billed in Place of Service 31, however the documentation provided does not confirm the enrollee 
was in a Skilled Nursing Facility on October 2, 2020, therefore these services cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiology services (HCPCS Q0092 and HCPCS R0070) provided to the enrollee on October 2, 
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 you would benefit from an IRF admission in order to build strength after an extended hospital stay. The Plan denied your request. The Plan says an IRF 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 in the Medicare rules section. 

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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis and altered mental status. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical tooth extraction (D7210) provided by an oral 
surgeon on August 20, 2020. 
 
You asked the Plan to pay for the extraction. You say that this was not a complicated extraction and should be 
covered. The Plan denied your request. The Plan says this service was not billed as a simple extraction and was 
provided by an oral surgeon rather than a general dentist. 
 
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 
surgical tooth extraction (D7210) provided by an oral surgeon on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on July 13, 2020. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was billed with an incorrect POS. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The services at issue were billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing (80307, G0483) provided on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for radiology studies.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says care must be received from network providers.

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 a referral to an out-of-network provider for radiology studies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on October 7, 2020. 
 
You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says it is important to 
know which providers are part of our network because, with limited exceptions, while the enrollee is a member 
of our plan, the enrollee must use network providers to get medical care and service. The only exceptions are 
emergencies, urgently needed care, when the network is not available, out-of-area dialysis services, and cases 
in which the Plan authorizes use of out-of-network providers.  
 
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 
home visit. 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 a home visit provided on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 26, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that due to cerebral palsy issues enrollee will 
need lift assist from EMS. 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 September 26, 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 for the ambulance services provided on September 26, 
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set-up portable x-ray equipment services coded Q0092 
and the transportation of portable x-ray equipment and personnel services coded R0070 provided on October 5, 
2020. 
 
You asked the Plan to pay for the set-up portable x-ray equipment services and the transportation of portable x-
ray equipment and personnel 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 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. 
 
We find that CPT codes Q0092 and R0070 are not supported in the medical record. Specifically, these codes 
have a professional component/technical component indicator of 3. These codes are a technical component 
only, therefore, should only be reported on a hospital setting. Place of Service code 31 should be used with 
services for enrollees in a Part A covered stay, and Place of Service code 32 should be used with services for 
beneficiaries in a noncovered stay and if the enrollee is in a Part A SNF stay, the transportation and set up costs 
are subject to consolidated billing and not separately billable. Based on this information, we decided that 
Medicare rules for coverage of the set-up portable x-ray equipment services and the transportation of portable 
x-ray equipment and personnel services have not been met. Therefore, we decided that the Plan does not have 
to pay for the set-up portable x-ray equipment services coded Q0092 and the transportation of portable x-ray 
equipment and personnel services coded R0070 provided on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4Kscore testing (81539) provided on August 17, 2020. 
 
You asked the Plan to pay for 4Kscore testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that due to significant issues with assay validation 
and absence of clinical utility, 4Kscore testing is not reasonable and necessary and is not covered by Medicare.  
 
We looked at the file and Medicare rules. The service at issue is not covered by Medicare. Therefore, we 
decided that the Plan does not have to pay for 4Kscore testing (81539) provided on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on September 14, 
2020. 
 
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this 
testing is eligible for payment when medically necessary. The Plan denied your request. The Plan says this 
service does not meet Medicare's criteria of medically necessary and reasonable and cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that for the  CxBladder assay coded as 0013M, non-
coverage was reaffirmed. 
 
We find that CPT code 0013M is not supported in the record. Specifically, this testing is not a covered benefit. 
Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been 
met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on 
September 14, 2020.