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

 
We decided that the Plan has to pay for FoundationOne Heme (F1Heme) comprehensive genomic profiling 
testing (81455) billed for date of service February 28, 2022. 
 
You asked the Plan to pay for F1Heme testing. You say that this panel was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim was billed with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that unless a certain exception is met, laboratory 
services should be billed with the date of service of the specimen collection.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of F1Heme testing have been met. Specifically, the record shows that the specimen in this case was 
collected while the enrollee was undergoing an outpatient surgical procedure. It would have been medically 
inappropriate to have collected this sample at a time other than during this visit, the service was medically 
necessary, and the results of this test did not guide treatment during this hospital stay. This means that an 
exception to the general rule has been met. When this specific exception is met, the correct date of service is 
the date the testing was performed. Therefore, we decided that the Plan has to pay for FoundationOne Heme 
(F1Heme) comprehensive genomic profiling testing (81455) billed for date of service February 28, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on May 3, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were never told that there 
would be a cost before the visit. The Plan denied your request. The Plan says the proper coinsurance was 
applied for the service that was rendered. 
 
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 Medicare-covered part B prescription drugs. The total amount charged for the injection was 
$1,002.24 with a coinsurance of $200.45 ($1,002.24 total amount x 20% coinsurance). 
 
  You have been asked to pay a $200.45 coinsurance for the injection. The injection falls within the Medicare 
Part B Prescription Drugs 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 
injection provided on May 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided at an 
out-of-network facility. 
 
You asked the Plan to pre-approve the services. You say that the enrollee needs to have a SNF in the location 
where she will be living. The Plan denied your request. The Plan says the requested SNF facility is out-of-
network and in-network facilities are available. 
 
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 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 medically reasonable or necessary. Our physician reviewer found that the requested 
service is not urgent or emergent. The enrollee was hospitalized following a fall. The enrollee is now ready for 
the next level of care. While the hospitalization was emergent and unforeseen, the discharge is foreseeable. SNF services are being requested. There is no documentation as to why the SNF services need to 
be provided at an out-of-network or out-of-area SNF. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided at an out-of-network facility.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 83789) provided to the 
enrollee on April 4, 2022. 
 
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 Current Procedural Terminology (CPT) code 83789-59 remains not supported. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 services Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the medical record includes a urine drug test with specimen validity. In this case, the work performed for specimen 
validity testing is included in CPT 80307 and HCPCS G0481. No additional testing was documented, in which 
Mass spectrometry testing is not inclusive to.  Therefore modifier -59 cannot be verified. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure code 83789) provided to the enrollee on April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth specialist visit provided on 
January 19, 2022. 
 
You asked the Plan to waive the copayment for a telehealth specialist visit. You say that this was covid related 
and should not have a copayment. The Plan denied your request. The Plan says this copayment 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 $40 
copayment for telehealth specialist visit.  
 
You have been asked to pay a $40 copayment for a telehealth specialist visit. A telehealth specialist visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayment for a telehealth specialist visit provided on January 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower limb prosthesis, vacuum pump, 
residual limb volume management and moisture evacuation system (L5781), an all-lower extremity prosthesis, 
multi-axial rotation unit (L5986) and an addition to lower limb prosthesis, vertical shock reducing pylon 
feature (L5988). 
 
You asked the Plan to pre-approve prosthetics. You say that the requested prosthetics are medically necessary. 
The Plan denied your request. The Plan says the request for vacuum-assisted socket system, shock reducing 
pylon and duplicate ankle does not meet Medicare criteria as reasonable and necessary. 
 
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 prosthetics. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not reveal you have had a significant change in function that requires 
these items which exceed your medical need. The request for vacuum-assisted socket system, shock reducing 
pylon and duplicate ankle does not meet Medicare criteria as reasonable and 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 prosthetics have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an addition to lower limb prosthesis, vacuum pump, residual limb volume management 
and moisture evacuation system (L5781), an all-lower extremity prosthesis, multi-axial rotation unit (L5986) 
and an addition to lower limb prosthesis, vertical shock reducing pylon feature (L5988).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 15, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the genetic testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 had network providers 
available who could have provided 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 genetic testing provided on April 15, 2022 by 
an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for BRCA1 and BRCA2 genetic testing (81162) provided on 
March 16, 2022. 
 
You asked the Plan to pay for BRCA1 and BRCA2 testing. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says the criteria for 
coverage of this testing are not met. In addition, this is not an approved test and has not been evaluated by the 
MolDx Program's technical assessment process. 
 
The Plan must follow Medicare rules. Medicare rules say that testing for the BRCA1 and BRCA2 genes is 
covered for patients suspected of hereditary breast and/or ovarian cancer syndromes. To be eligible for 
Medicare coverage, the individual being tested must have signs or symptoms of breast, ovarian, pancreatic or 
prostate cancer and meet at least one additional criterion. 
 We looked at the file and Medicare rules. The documentation provided does not include any evidence that the 
enrollee has a personal history of breast, ovarian, pancreatic or prostate cancer or is being evaluated for any 
possible symptoms of these cancers. The documentation only indicates that the enrollee has family history of 
multiple cancers. Based on this information, we decided that Medicare rules for coverage of BRCA1 and 
BRCA2 testing have not been met. Therefore, we decided that the Plan does not have to pay for BRCA1 and 
BRCA2 genetic testing (81162) provided on March 16, 2022.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you need can be provided safely 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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain her functional status. You can receive further services at a 
lower level of care. Our physician reviewer found that your 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.
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 this is medically necessary. The Plan denied your 
request. The Plan says the services are 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 in this case, the complexity of your nursing, medical and rehabilitation needs do 
not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an 
intensive rehabilitation therapy program. You continue to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement; however, the documentation doesnt support that you 
meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would 
require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain your functional status. You can receive further 
services at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely 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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for 
functional improvement however, the documentation doesnt support that you would meet criteria for 
admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain his functional status. You can receive further services at a 
lower level of care. Our physician reviewer found that your 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.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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 your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy 
program. 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 inpatient rehabilitation facility. You continue to have a 
need for skilled therapy with ongoing safety concerns and a potential for functional improvement however, the 
documentation doesnt support that you meet criteria for admission to an acute inpatient rehabilitation facility. 
There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your 
functional status. You can receive further services at a lower level of care. Our physician reviewer found that 
your 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total hip arthroplasty (27130) provided on December 8, 
2021. 
 
You asked the Plan to pay for the total hip arthroplasty (27130). You say that the operative report shows the 
enrollee had a total hip arthroplasty and CPT code 27130 is the same surgery. You say that the denial is 
incorrect, and the claim should be processed for payment. The Plan denied your request. The Plan says 
procedure code 27130 is not supported by the medical records submitted. 
 
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 27130 is arthroplasty, acetabular and proximal femoral 
prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. 
  We asked our coder 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 total hip arthroplasty (27130). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report does not include enough documentation to confirm a total hip arthroplasty has been 
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 total hip arthroplasty (27130) have not been met. Therefore, we decided that 
the Plan does not have to pay for the total hip arthroplasty (27130) provided on December 8, 2021.