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

 
We decided that the Plan has to pay for outpatient services (96361, J7030, 96374, 96375, 99285, J0780, J1200, 
J2765) provided on February 8, 2020. 
 
 
You asked the Plan to pay for outpatient services. You say that these services were appropriate and medically 
necessary. The Plan denied your request. The Plan says that these services are not separately payable from an 
inpatient hospital admission. 
 
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. Specifically, the case file does not contain documentation showing that the 
enrollee was admitted as an inpatient or that inpatient services were billed and paid by the Plan. The services in 
question were billed with a type of bill code indicating they were provided in an outpatient setting. The Plan 
indicates that these services are not separately payable from the payment made for inpatient services, but the 
documentation provided by the Plan does not corroborate this rationale. We do not find the Plan denial to be 
substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for outpatient 
services (96361, J7030, 96374, 96375, 99285, J0780, J1200, J2765) provided on February 8, 2020. 
  
 
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 lab services provided to the enrollee on November 13, 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 because Comprehensive Genomic Profile (CGP) testing is not defined as a targeted 
panel by MolDX. It is a test not currently satisfactorily described by any existing CPT code. To report a CGP, 
service providers should use CPT code 81479 in addition to the approved DEX Z-CodeTM. Coverage of CGP 
is limited to one test per specimen and precludes the use of any other molecular testing on the specimen. 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 November 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services provided on November 1, 2019 through November 
30, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that this provider is not Medicare certified. 
 
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. Specifically, the record does not confirm that the provider in this case was not 
participating or excluded from Medicare coverage for the dates of service at issue. The provider appears to 
have been active with Medicare for the dates of service at issue. The Plan indicates that there are no active rates 
for this provider, but the documentation provided by the Plan does not corroborate this rationale. We do not 
find the Plan denial to be substantiated and we must find in your favor. Therefore, we decided that the Plan has 
to pay for outpatient services provided on November 1, 2019 through November 30, 2019.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 17, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on February 17, 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 22, 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 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 80053, 85025, 80061, 82248, 83695, 83735, 84550, 
83090 and 84443 provided to the enrollee on December 10, 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 while a portion of this claim was paid, Medicare billing criteria are not met for codes 
80053, 85025, 80061, 82248, 83695, 83735, 84550, 83090 and 84443. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must submit records that support the services billed were done so appropriately by a physician.  
Based on the medical records provided, the documentation provided does not support the services billed.  
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services provided to the enrollee on December 10, 2019 and billed under codes 80053, 
85025, 80061, 82248, 83695, 83735, 84550, 83090 and 84443.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on April 7, 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 Medicare billing criteria were not met. 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 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for screening tests provided to the enrollee on April 8, 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 type of screening 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, this service, 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 screening tests provided to the enrollee on April 8, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 11, 2019 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that you would like these services covered. You 
did not provide further argument for coverage. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for medical services provided on March 11, 2019 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the thorax (71270). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration because the CT 
Scan is medically necessary. The Plan denied your request. The Plan says no clinical information has been 
received to establish medical necessity for the CT Scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT Scan. Our reviewer says that 
based on the medical records provided and the current guidelines for the management of pulmonary nodules 
there is no documentation that a follow-up CT scan for the nodule is medically reasonable and necessary. Our 
physician reviewer found the previous scan showed the nodule unchanged or slightly smaller at 3-5 mm in size. 
 
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 CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the thorax (71270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable concentrator is 
medically necessary. The Plan denied your request. The Plan says you are currently renting stationary and 
portable concentrators that meet your needs. 
 
The Plan must follow Medicare rules. The rules say that only rented oxygen equipment is covered. 
 
We looked at the file, and Medicare rules. The request is for coverage of purchased oxygen equipment. Based 
on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator 
(E1392).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electroconvulsive treatment. 
 
You asked the Plan to pre-approve the electroconvulsive treatment. You say that you would like 
reconsideration because this is the best course of treatment for the member. The Plan denied your request. The 
Plan says the member has not tried many pills without getting better. 
 
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 electroconvulsive treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the dosage and duration of antidepressant treatment is not clearly 
documented. 
 
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 electroconvulsive treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve electroconvulsive treatment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on February 3, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the medical records do not contain a valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and provide valid physician documentation. In 
this case, the file does not contain documentation of an established relationship between the enrollee and the 
ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage 
of this testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing 
provided to the enrollee on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provide to the enrollee on March 17, 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 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 testing provide 
to the enrollee on March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on November 21, 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 medical records indicate that urine testing was performed. There is a more 
appropriate CPT code that should be used to bill for the service provided. The specimen type collected is 
incorrect for the billed codes; therefore, the codes cannot be verified. The Plan states this test is performed on a 
blood specimen collected by venipuncture.  The submitted toxicology request form indicates the specimen was 
urine. It is noted multiple attempts were made to obtain additional information from the provider. 
 
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 issue is with the specimen type 
reported to have been used for this testing. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on November 
21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the PWC. You say that you believe that you would benefit from a PWC and 
that it would better meet your needs. The Plan denied your request. The Plan says the records provided do not 
show that your mobility needs could not be met with an optimally configured manual wheelchair or even a 
power scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 PWC. Our reviewer says that the 
requested PWC is not considered reasonable and necessary at this time. Our physician reviewer found the 
enrollee has spinal stenosis with a history of surgery and potential planned removal of hardware. His manual 
wheelchair is in disrepair and it is felt that a power wheelchair would be a better option. The enrollee has some 
mild limitation of range of motion on exam. There is no documented muscle atrophy. 
 
In this case, the patient is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, 
standard manual wheelchair, or use of a scooter). Therefore, this request is not 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 PWC have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory viral panel rendered on December 27, 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 non-covered. 
 
The Plan must follow Medicare rules. The rules say that multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The services at issue are a respiratory viral panel of 6 or more 
pathogens. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to 
pay for the respiratory viral panel rendered on December 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full mouth debridement for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is needed to enable comprehensive evaluation 
and diagnosis. The Plan denied your request. The Plan says there are other treatments which may be medically 
appropriate or necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found full mouth debridement (D4355) does not meet the criteria for coverage since full mouth debridement 
would not be done; only 11 mandibular teeth are present and the maxillary arch is edentulous. Other treatments 
such as scaling and root planing (D4341) could be used. 
 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve full mouth debridement for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy (PT) sessions (beyond 8 
approved). 
 
You asked the Plan to pre-approve the continued PT sessions. You say that you are able to do some exercises at 
home; however, you feel that you are able to focus on different therapies in the sessions which are helpful. The 
Plan denied your request. The Plan says you should be able to continue with your home exercise program 
without needing further in-office therapy sessions. 
 
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 the continued PT sessions. 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 for shoulder pain, physical therapy (PT) is generally 
accepted as specific and effective therapy.  Goals include reducing pain, restoring function, and educating 
regarding a home exercise program (HEP) prior to transition towards a home program.  
 
In this case, there is no indication prior PT has served to provide sustained, significant improvement in pain 
and/or function and there is no indication residual deficits could not be addressed via a home exercise 
program. Therefore, this request is deemed not 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 continued PT sessions have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional physical therapy (PT) sessions (beyond 8 approved).