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

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 7, 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 per Medicare guidelines, REV code 0637, if included on the claim is required to include a HCPC 
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 the various denied CPT codes are not supported in the medical record. Specifically, the revenue 
code on the claim did not contain a HCPC code. 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 
laboratory services provided to the enrollee on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 23, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order 
to receive reimbursement from Federal programs.  
 
We looked at the file and Medicare rules. The file shows that the services at issue are excluded from CLIA 
edits. 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 laboratory services rendered on October 23, 
2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an x-ray of the chest provided to the enrollee on March 10, 2020. 
 
You asked the Plan to pay for the x-ray. You say that this should be paid for. The Plan denied your request. The 
Plan says that this was not reported with a diagnosis that supports the procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the x-ray. Our reviewer says that the 
requested x-ray of the chest is considered medically reasonable and necessary in this case. Our physician 
reviewer found the issue in this case is whether the ordered and interpreted two-view chest x-ray was medically 
necessary for the enrollee, and whether the history of "smoking" qualifies as an appropriate history. In patients 
with a smoking history, clearly the risk of lung cancer is higher than in non-smokers. Based upon the clinical 
history provided it cannot be determined if the patient was a candidate for the more sensitive test - LDCT. In 
particular, the number of pack years and whether the enrollee is still smoking or has quit in the past 15 years 
cannot be determined. The exam was completed per order and includes a history indicating increased risk of 
lung cancer. The plan has submitted one journal article arguing against screening chest x-ray in smoking 
patients but the article by no means establishes the standard of care when LDCT coverage is unknown or not 
possible. 
 
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 x-ray have been met. Therefore, we decided that the Plan has to pay for an 
x-ray of the chest provided to the enrollee on March 10, 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 the Guardant360 testing provided on May 19, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on May 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, 
L2385) provided to the enrollee on April 5, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says There is no itemized billing/shipping invoice to verify the services billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a proof of delivery to support medical necessity for the supplies provided in this 
case. There is no itemized billing/shipping invoice to verify the services billed. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397, L2385) provided to the 
enrollee on April 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 by an 
OON provider. 
 
You asked the Plan to pay for the medical services. You say that you depend upon the hospital staff to verify 
eligibility and to obtain the prior authorization for in-network and out-of-network providers from the member's 
insurance. The Plan denied your request. The Plan says nursing care services require pre-approval prior to 
rendering the service, in addition, the Plan requires the utilization of in-network providers unless the Plan pre-
approves out-of-network services in non-emergent situations. The Plan states the provider did not make 
attempts to verify the member's correct insurance, eligibility, or authorization requirements prior to rendering 
non-emergent services. The Plan states there is no evidence of plan directed care and the member was not 
receiving skilled services or inpatient services during this time. 
 
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 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 the medical services provided on September 16, 
2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the diagnostic mammography provided on 
July 20, 2020. 
 
You asked the Plan to waive the deductible for the diagnostic mammography. You say that you went in for a 
routine mammogram so the claim should be paid. The Plan denied your request. The Plan says you had not met 
your deductible at the time of service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible for plan deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category plan 
deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible. This cost sharing is a contractual obligation that had not been met at the time the diagnostic 
mammography was received on July 20, 2020. The deductible does not apply to a screening mammogram, 
however this claim is for a diagnostic mammogram. Therefore, we decided that the Plan does not have to waive 
the deductible for the diagnostic mammography provided on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit services provided on May 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the office visit services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an out of network provider. 
 
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 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 the office visit services provided on May 13, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the darbepoetin alfa injection rendered on 
May 4, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that the cost share was higher than it 
has previously been. The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for chemotherapy and other drugs covered by Medicare Part B.  
 
Review of the file shows that you received a darbepoetin alfa injection rendered on May 4, 2020. You have 
been asked to pay a 20% coinsurance for these services, for a total of $146.80. These services fall within the 
chemotherapy and other drugs covered by Medicare Part B 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 the darbepoetin alfa injection rendered on May 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and 
effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does 
not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist 
to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 
SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a 
skilled nursing facility setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 provided on December 13, 
2019. 
 
You asked the Plan to pay for the drug testing. 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 80307 is drug test(s), presumptive, any number of drug 
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay 
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry 
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, 
MALDI, TOF) includes sample validation when performed, per date of service. 
 
We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation submitted 
did not include a valid physician order/lab requisition or medical records (signed by the ordering physician). 
Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 provided on 
December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration (96372 and J9217) provided on 
May 13, 2020. 
 
 
You asked the Plan to pay for the chemotherapy. You say that you would like reconsideration because you 
thought your doctor would have obtained prior authorization. The Plan denied your request. The Plan says prior 
authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of the chemotherapy have not been met. Specifically, the record indicates that this was a 
non-urgent non-emergent chemotherapy treatment session for which prior authorization would be required. 
Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96372 and J9217) 
provided on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre CGM system. You say that the items are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 
met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Freestyle Libre CGM system. Our 
reviewer says that the items are not medically necessary. Our physician reviewer found Lantus SoloStar is an 
insulin that is administered once daily. The coverage criteria for a CGM have not been met in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional home health physical therapy visits. You say that the 8 
additional home health physical therapy visits are medically necessary. The Plan denied your request. The Plan 
says the 8 additional home health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 8 additional home health physical 
therapy visits. Our reviewer says that the 8 additional home health physical therapy visits are not medically 
necessary. Our physician reviewer found the enrollee is with a past medical history of Parkinson's disease, 
hypertension, diabetes and chronic kidney disease who has been receiving skilled home health services for care 
of multiple medical problems after a hospitalization in August 2020 for low blood pressure.  
 
Based on the medical records provided there is no documentation that the skilled therapy services are required 
to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent 
deterioration. He is modified independence for transfers and stand-by assist/supervision for gait (100-125 feet 
with a walker). There is no indication in the records of a physician order for the additional requested 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 8 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 8 additional home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 2, 
2019, to December 20, 2019. 
 
You asked the Plan to pay for the acute inpatient care. You say that this was medically necessary. The Plan 
denied your request. The Plan says the enrollee's previous plan is responsible for payment for these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan that covered the enrollee at the 
beginning of an inpatient stay is responsible for the entire stay. If there is a change in coverage during the stay, 
the new Plan is not responsible for inpatient hospital care until after the date of discharge.  
 
A different health plan was not the Plan of record at the time of the inpatient stay at issue in this appeal began. 
This means that the new plan is not responsible for coverage of inpatient hospital services until after this stay 
ended. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided 
from December 2, 2019, to December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99203 provided on January 17, 2020. 
 
You asked the Plan to pay for the office visit. 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 99203 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A detailed history; A detailed 
examination; Medical decision making of low complexity. Counseling and/or coordination of care with other 
physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 
problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. 
Typically, 30 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, this service is only to be 
billed for new patients. The documentation does not support that the enrollee was a new patient to this 
provider. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99203 provided on 
January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mechanical traction therapy (97012) and diathermy therapy 
(97024) provide from May 12, 2020, to May 14, 2020. 
 
You asked the Plan to pay for mechanical traction therapy and diathermy therapy. You say that you believed 
you only received standard chiropractic services. The Plan denied your request. The Plan says these services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for mechanical traction therapy (97012) and diathermy therapy (97024) provide 
from May 12, 2020, to May 14, 2020.