Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device and accessory to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and accessory. You say that the in-network 
provider does not cover this specific item. The Plan denied your request. The Plan says  
 
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 pneumatic compression device and accessory to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215), psychotherapy, 30 minutes (90833), 
and interactive complexity (90785) provided on February 3, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services provided were not related 
to the enrollee's terminal condition. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked.  The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99215), psychotherapy, 30 minutes (90833), 
and interactive complexity (90785) provided on February 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this is necessary for you. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 
continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing 
provided on March 21, 2022. 
 
You asked the Plan to pay for the comprehensive hereditary pharmacogenomic 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.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The comprehensive hereditary pharmacogenomic testing at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the comprehensive hereditary pharmacogenomic testing provided on March 
21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on March 16, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you have provided medical records to support the 
services at issue. The Plan denied your request. The Plan says rules for payment for MDT services have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that all MDT services must include an identifier as 
additional claim documentation. 
 
 
  We looked at the file and Medicare rules. In this case, the claim for the services at issue was not submitted with 
a unique test identifier. Based on this information, we decided that Medicare rules for coverage of genetic 
testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) 
provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 5, 2021 billed with codes 
82106 & 81292. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the codes billed are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
July 5, 2021 billed with codes 82106 & 81292.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
February 27, 2021, to March 5, 2021. 
 
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 provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872. 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 enrollee was admitted to the hospital, 
presenting with diarrhea, vomiting, and sacral pain and was diagnosed and treated for urinary tract infection. 
Initially the patient had tachycardia, moderately elevated blood pressure, mild leukocytosis, and without fever. 
The patient was oriented x3, platelets were normal, bilirubin was 4.1, Cr was 2.65, and lactic acid was 7.8. 
However, the bilirubin and creatinine were noted to be near his baseline based on alcoholic steatohepatitis and 
chronic kidney disease, and the calculated SOFA score was 0 indication low likelihood of sepsis being present. 
The Sepsis 3 criteria was not met and, therefore, the diagnosis of sepsis was not supported in the 
documentation. Therefore, the appropriate DRG would be 690.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from February 27, 2021, to March 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for an injection provided on February 11, 2022.        
 
You asked the Plan to waive the coinsurance for an injection. You say that you have met your maximum out-
of-pocket (MOOP). The Plan denied your request. The Plan says that the claim was processed correctly based 
on your benefits at the time the services were rendered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a summary of the 2022 maximum out-of-pocket 
amount. Without this information, the plans denial is not able to be substantiated. Therefore, we decided that 
the Plan has to waive the coinsurance for an injection provided on February 11, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 23, 
2022. 
 You asked the Plan to pay for procedure code 83789. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 
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, we have confirmed that code 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 83789 billed for date of service February 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0018U and 0245U) provided on 
March 22, 2022. 
 
You asked the Plan to pay for codes 0018U and 0245U. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. 
 
We find that codes 0018U and 0245U are not supported in the medical record. Specifically, there is no 
documentation describing genetic testing on a sample collected on the date of service at issue. Therefore, we decided that the Plan does not have to pay for the laboratory services (0018U and 0245U) provided on March 
22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on March 2, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the documentation shows 
that the specimen was collected on December 8, 2021. This means there is no documentation to support the 
date of service billed. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
coded 81479 provided on March 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from 
additional care at the LTACH level. The Plan denied your request. The Plan says according to the clinical 
documentation, the current care plan can be provided at an alternative level of care. 
 
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 that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can be safely administered at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from December 27, 2021, to December 31, 2021. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 pay for skilled nursing facility (SNF) services provided to the enrollee from December 27, 2021, to 
December 31, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 
27, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you disagree with the Plan's 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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 
 We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that these services were performed by a physical therapist assistant in a home health or hospice setting. This 
means there is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on August 27, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 test provided on February 1, 2022. 
 
You asked the Plan to pay for a COVID-19 test. You say that you were told by a Plan representative that your 
request would be accepted, and a check would be forthcoming. The Plan denied your request. The Plan says per 
the Centers for Medicare and Medicaid Services (CMS), the Plan may, but is not required by federal law to 
provide coverage for over-the-counter at-home COVID-19 tests. The Plan also says that if the member gets 
services that are non-covered, the member must pay for the services themselves. 
 
The Plan must follow Medicare rules. Medicare rules say that if you are in a Medicare Advantage (MA) plan, 
the tests covered under this initiative will be covered outside of your existing plans coverage, and in addition 
to any over-the-counter tests that may be covered under the plan as a supplemental benefit. The Medicare rules 
also say that this initiative started on April 4, 2022. 
 
  We looked at the file and Medicare rules. This test is not covered by Medicare because it was purchased prior 
to April 4, 2022. Based on this information, we decided that Medicare rules for coverage of a coronavirus 
(COVID-19) test have not been met. Therefore, we decided that the Plan does not have to pay for COVID-19 
test provided on February 1, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee on 
August 3, 2021. 
 
You asked the Plan to pay for the services. You say that the plan should process this claim under the correct 
benefit. The Plan denied your request. The Plan says that payment will be reconsidered whenever a corrected 
claim is provided. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan's denial reason is vague. The plan has not explained what the "required 
code 50" is. The plan says that payment will be considered whenever a corrected claim is provided but have not 
specified what is needed to be included in the corrected claim. Therefore, we decided that the Plan has to pay 
for skilled nursing facility (SNF) services provided to the enrollee on August 3, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the inpatient detoxification (detox) and alcohol 
rehabilitation services provided on September 15, 2021, to October 12, 2021. 
 
You asked the Plan to reimburse you for the detox and rehabilitation services. You say that you were in need of 
urgent medical attention and intervention. You say that you sought medical attention from your primary care 
physician. You also say that you agreed your condition was acute and needed to enter a facility for help. The 
Plan denied your request. The Plan says the facility in this case does not participate with Medicare, therefore 
payment cannot be made. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for the inpatient detoxification 
(detox) and alcohol rehabilitation services provided on September 15, 2021, to October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 24, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on March 24, 2022, by an 
out-of-network (OON) provider.