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

 
We decided that the Plan does not have to pay for the albuterol (J7620) and pharmacy dispensing fee for 
inhalation drug (Q0513) provided from March 5, 2022, to April 6, 2022, by an out-of-network pharmacy. 
 
You asked the Plan to pay for the Part B prescription drugs. You say that you receive your Part D medications 
from this pharmacy, and they are covered. You say that you thought these drugs were covered under your Part 
D plan. You also say that you did not know this pharmacy was out-of-network with your plan. The Plan denied 
your request. The Plan says there are in-network providers available in your area. 
 
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 the albuterol (J7620) and pharmacy dispensing fee for inhalation drug (Q0513) provided from 
March 5, 2022, to April 6, 2022, by an out-of-network pharmacy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 19, 2019. 
 
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 were billed incorrectly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the laboratory services was not filed until March 22, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
December 30, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). The Plan denied your request. The 
Plan says there is insufficient documentation to corroborate the services. 
 
  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of hospital discharge day management 
(99239) provided on December 30, 2021, have been met. Specifically, medical records for this date of service 
were not submitted. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99239) provided on December 30, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the next generation sequencing provided on November 4, 2021. 
 
You asked the Plan to pay for the testing services. You say that molecular testing plays an important role in 
making a definitive diagnosis. The Plan denied your request. The Plan says that the testing is not a covered 
benefit. 
 
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. 
 
We looked at the file and the rules. In this case, the testing was provided to the enrollee, who presented with a 
solid tumor. No other valid denial rationale was presented by the Plan. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the next generation sequencing provided on November 4, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 6-month supply of Ensure Plus. 
 
You asked the Plan to pre-approve Ensure Plus. You say that the enrollee needs these supplements. The Plan 
denied your request. The Plan says oral supplements are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve a 6-month supply of Ensure Plus.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you cannot afford to pay out-of-pocket for the office 
visit. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on May 2, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic care to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve chiropractic care to be provided by an OON provider. You say that the 
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able 
to provide these services. Therefore, coverage criteria have not been met. 
 
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 
chiropractic care to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent; other peripheral nerve 
or branch (64640). 
 
You asked the Plan to pre-approve CryoTherapy. You say that the enrollee reported 80% relief from the 
psychoneuroimmunology (PNI) for greater than 24 hours. You say that the enrollee is a good candidate to 
receive long term relief from the cryotherapies. The Plan denied your request. The Plan says the requested 
service is not medically 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 CryoTherapy. Our reviewer says that 
the requested CryoTherapy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested CryoTherapy is considered a nerve block. The records do not support that the 
LLCD criteria have been met. The records do include evidence of an evaluation which assesses the source of 
the pain. However, the records do not support that the requested cryotherapy is medically reasonable and 
necessary to treat the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CryoTherapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent; other peripheral nerve or branch (64640).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unclassified drug injection (J3490) billed on May 18, 
2021. 
 
You asked the Plan to pay for the unclassified drug injection (J3490). You say that J3490 is an unclassified 
code that is associated with compound medications. You say that there is no allowable amount for J3490, and it 
should be paid at invoice cost which is 10% less than the billed charges. The Plan denied your request. The 
Plan says the medical records indicate that Hydromorphone was administered and there is a more appropriate 
code for the service provided. 
 
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 J3490 is drugs unclassified injection. 
  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 unclassified drug injection (J3490). Our reviewer says 
that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer 
found that the provider documents Hydromorphone administration. In this case, an unclassified drug code 
would not be reported as there is a more appropriate code to report for the service 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 unclassified drug injection (J3490) have not been met. Therefore, we 
decided that the Plan does not have to pay for the unclassified drug injection (J3490) billed on May 18, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care provided on March 19, 2021. 
 
You asked the Plan to pay for initial hospital care. You say that the physician provided medically necessary 
care to the enrollee in good faith. The Plan denied your request. The Plan says original Medicare is responsible 
for payment. 
 
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 initial hospital care provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 23, 2022. 
  You asked the Plan to pay for the office visit. You say that you want to correct the claim to have modifier -24 
on the line item. The Plan denied your request. The Plan says this service is part of the global surgical fee 
because it was reported within the global period of a major surgical procedure. 
 
The Plan must follow Medicare rules. The rules say that the Medicare approved amount for certain procedures 
includes payment for certain services related to the surgery when furnished by the physician who performs the 
surgery.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the claim has not been billed with a modifier to 
indicate that this was unrelated to the surgery performed on April 5, 2022. Therefore, we decided that the Plan 
does not have to pay for the office visit provided on May 23, 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 the admission is medically necessary. The Plan 
denied your request. The Plan says the requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the provided documentation does not indicate that you have complex nursing or 
rehabilitation needs. The reviewer found that while there is a need for therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therefore, the reviewer found that the requested IRF admission is not medically reasonable 
or 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on April 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that this was medically necessary. The 
Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also 
says that the services were not referred by a network provider or rendered in an in-network facility. The Plan 
also says that they have also determined that these services are not urgent or emergent, nor were they approved 
in advance. 
 
 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 a hospital outpatient clinic visit provided on April 
22, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
October 26, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the billing process was delayed due to the 
pandemic, being short staffed, and an overwhelming increase of patient flow. The Plan denied your request. 
The Plan says the claim was not filed within 12-months of the date of service in this case. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the nursing facility care was not filed until March 7, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on October 
26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided from April 11, 
2022, through April 12, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided from April 11, 2022, through April 12, 2022.   
Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on February 10, 2022. 
 You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not support the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, the medical records do not indicate the testing was ordered by 
the enrollees treating physician as part of treatment for a specific medical problem. Based on this information, 
we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on February 10, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from March 10, 2022, to 
March 12, 2022. 
 
You asked the Plan to pay for SNF care. You say that skilled nursing services were medically necessary. The 
Plan denied your request. The Plan says that daily skilled services were not medically necessary and services 
could have been provided at the custodial level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that clinical documentation showed the enrollee had difficult to manage medical and 
behavioral conditions in which skilled nursing services were medically necessary. Our physician reviewer also 
found clinical documentation showed that the enrollee had functional impairments and required evaluation and 
treatment by skilled therapy. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for skilled nursing 
facility (SNF) care provided from March 10, 2022, to March 12, 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 pay for the hysterectomy and related services provided on January 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hysterectomy and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
hysterectomy and related services. We found no exception that would require the Plan to pay for the 
hysterectomy and related services. The records provided for review do not show that the hysterectomy and 
related services were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the 
hysterectomy and related services provided on January 7, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing billed for services provided on 
February 10, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not support testing on the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. In this case, there are insufficient medical records from the treating 
physician to show that the coverage criteria have been met for the provided testing. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing billed for services provided on February 10, 2022.