Persius/hicric huggingface dataset:
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 enrollee requires SNF care. The Plan denied 
your request. The Plan says daily skilled services are not required. 
 
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 pre-approve 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 the enrollee was admitted to the hospital on September 28, 2022, for pneumonia. The 
enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled 
therapy needs. The enrollee is not shown to have an acute decline in function. Daily skilled services are not 
shown to be required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs, custodial and intermittent, can, as a practical matter, be provided 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is not enough scientific evidence that this treatment is effective for the enrollee's 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this is considered an experimental procedure because of the wide variation in efficacy reported in the 
peer reviewed literature. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you would like the Plan to reconsider 
payment. The Plan denied your request. The Plan says there are in-network providers who are available to 
provider the required services. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reduce the copayments for the outpatient office visits (99213) provided on 
January 10, 2022, and April 11, 2022. 
 
You asked the Plan to reduce the copayments for the outpatient office visits. You say that you thought these 
services were routine eye exams. The Plan denied your request. The Plan says that you pay $50.00 for services 
from an in-network provider. 
 
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 enrollees must pay a $20 copayment for Vision Care.  
 
The Plan says you must pay a $50 copayment for the outpatient office visits. Based on the Plan contract, 
however, you cannot be asked to pay more than a $20 copayment for the outpatient office visits. Therefore, we 
decided that the Plan has to reduce the copayments for the outpatient office visits (99213) provided on January 
10, 2022, and April 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 unlisted molecular pathology procedure (81479) provided 
April 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that please find a copy of all available medical 
records you have obtained from the referring provider. The Plan denied your request. The Plan says services do 
not meet coverage requirements. 
 
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 81479 is unlisted molecular pathology procedure. 
 We find that CPT code 81479 is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimens were collected 
on December 7, 2021, and February 22, 2022, rather than the billed date of service April 1, 2022. The date of 
service for a clinical laboratory test or the technical component of physician pathology service must be the date 
the specimen was collected. 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 unlisted 
molecular pathology procedure (81479) provided April 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional hours for personal care services. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is no additional information provided with the appeal to show why the 
assessment is inaccurate, and why additional hours should be approved. 
 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 the additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
that there is limited timely documentation to show that additional approval of personal care hours is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional hours for personal care services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing provided on 
September 3, 2021, billed with code 0037U. 
 
You asked the Plan to pay for the genetic testing billed. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says this service is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
We looked at the file and Medicare rules. The next generation sequence testing (NGS) testing panel performed 
included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is statutorily excluded 
service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
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 FoundationOne CDx (F1CDx) 
testing provided on September 3, 2021, billed with code 0037U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory work provided on December 28, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that you were required to be tested for COVID-19. 
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 
laboratory work. We found no exception that would require the Plan to pay for the laboratory work. Therefore, 
we decided that the Plan does not have to pay for the laboratory work provided on December 28, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to provide reimbursement for the COVID-19 testing provided on December 28, 
2021. 
 
You asked the Plan to provide reimbursement for the COVID-19 testing. You say that you did as you were told 
in order to get these services paid. You feel that this denial is incorrect. The Plan denied your request. The Plan 
says that these services were provided out-of-network and were not authorized as required. 
 
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. Your appeal request indicated that you contacted the Plan prior to receiving 
these services. You state that you were told that you would just need to request reimbursement and were 
directed to the correct forms. The Plan has not addressed this. Though the Plan notes that authorization is 
required for out-of-network testing, but the phone call to the Plan was not addressed. Depending on the 
information in the phone call, the Plan should have allowed you to request authorization for the necessary 
testing from an out-of-network. Since there is no evidence that you were offered prior authorization review, we 
find that this is not a valid denial rationale for these services. Therefore, we decided that the Plan has to provide 
reimbursement for the COVID-19 testing provided on December 28, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99204), scanning computerized 
ophthalmic diagnostic imaging (92133), ophthalmic biometry (92136), ophthalmic ultrasound (76514), 
microfluidic analysis (83861), and immunoassay for analyte other than infectious agent antibody or infectious 
agent antigen (83516) provided on March 11, 2022, by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the outpatient office visit, diagnostic imaging, ophthalmic biometry, ophthalmic 
ultrasound, microfluidic analysis, and immunoassay. You say that the enrollee was referred by their primary 
care provider. You also say that these services were medically necessary to determine the cause of the 
enrollee's headaches. The Plan denied your request. The Plan says both the referring and attending providers 
are all non-participating with the Plan. The Plan also says that prior authorization was not 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 
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 outpatient office visit (99204), scanning 
computerized ophthalmic diagnostic imaging (92133), ophthalmic biometry (92136), ophthalmic ultrasound 
(76514), microfluidic analysis (83861), and immunoassay for analyte other than infectious agent antibody or 
infectious agent antigen (83516) provided on March 11, 2022, by an out-of-network (OON) provider.
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 requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 
 
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 pre-approve 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 based on the documentation provided, the enrollee does not have documented skilled 
nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be 
functioning at her baseline. Daily skilled services are not required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided 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 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 laboratory services provided on June 16, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 code 0090U is 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 provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided on May 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that submission of clinical records support approval for 
the services. The Plan denied your request. The Plan says care must be received from a 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 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 genetic testing (81479) provided on May 17, 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 genetic testing provided on March 27, 2022 billed with 
codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87591, 87640, 87641, 87651, 87653, 87661 and 
87798. 
 You asked the Plan to pay for the genetic testing billed. You say that you are an independent diagnostic 
laboratory that tests Pathology, Medication management and toxicology samples sent from clinics and 
providers for patients they have determined require such testing. The Plan denied your request. The Plan says 
this service is PCR testing is considered unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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 
March 27, 2022 billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87591, 87640, 87641, 
87651, 87653, 87661 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 14, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 14, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 26, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93010 billed for date of service December 7, 
2021. 
 
You asked the Plan to pay for procedure code 93010. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93010 is bundled into 
payment for code 36556. 
 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 93010 
is a column II code to column I code 36556. 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 93010 billed for date of service December 7, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this should be paid for. The Plan denied your 
request. The Plan says this does not serve a primarily medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transport chair provided on February 24, 2022. 
 
You asked the Plan to pay for the transport chair. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
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 pay for the transport chair provided on February 
24, 2022.