Persius/hicric huggingface dataset:
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee 
may benefit from physical therapy, the enrollee's rehab needs can be safely met with continued therapy and not 
an IRF admission. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 71045 is not supported. 
 
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 71045 is chest x-ray, single view. 
 
We find that CPT code 71045 is not supported in the medical record. Specifically, there is no documentation of 
a single view chest x-ray for the date of service at issue. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the chest x-ray rendered on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on May 27, 2021. 
 
You asked the Plan to pay for the testing services. You say that you were compliant with regulations for billing. 
The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We looked at the file and the rules. The claim billed a place of service as an independent laboratory. The rules 
say that if an independent lab bills for services, the place where the sample was taken is reported as the place of 
service. The records do not show that the specimen was obtained at the independent laboratory. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing services provided on May 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the requested item is medically 
necessary at this time based on the enrollee's condition, risk factors and comorbidities. The Plan denied your 
request. The Plan says the enrollee does not meet the requirement for coverage and this item is not covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for coverage. 
 
 
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 documentation does not support that the complexity of your needs requires an acute hospital inpatient stay. Skilled therapy services may 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital care visit provided 
from November 13, 2021, to November 18, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital care visit. You say that the services 
should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $370 copayment per day for days 1-5 of Inpatient hospital care.  
 
The enrollee has been asked to pay an $1,850 copayment for 5 days of inpatient hospital care ($370 x 5 = 
$1,850). This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital care visit 
provided from November 13, 2021, to November 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services provided on June 15, 2020. 
 
You asked the Plan to pay for the services provided. You say that you are requesting in-network benefits. The 
Plan denied your request. The Plan says the code remains not supported. 
 
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 97110 is not supported in the medical record. The records show that the physical 
therapy services at issue were provided at the enrollees home. There is a more appropriate code to describe 
home health physical therapy services available. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the physical therapy services provided on June 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) provided on February 24, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice on 
the date of service in this case. 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. 
  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on February 19, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
service, advanced life support, emergency transport (A0427), and ground mileage (A0425) provided on 
February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vaccine for shingles (90750) and administration (90471) 
provided on September 23, 2021. 
 
You asked the Plan to pay for the vaccine services. You say that this vaccine was medically necessary. The 
Plan denied your request. The Plan says this service was rendered by an out-out-network provider. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine services. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the vaccine 
services. Therefore, we decided that the Plan does not have to pay for the vaccine for shingles (90750) and 
administration (90471) provided on September 23, 2021.  
 
 
 
 
 
 
 
 
 Benefits for the vaccine services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence wipes (E1399).
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee suffers from incontinence
and needs the wipes. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Fulphila (Q5108).
You asked the Plan to pay for Fulphila. You say that this is medically necessary. The Plan denied your request.
The Plan says this use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Fulphila. Our reviewer says that the
requested use of Fulphila is not supported. Our physician reviewer found the record indicates that the requested
drug is being used as prophylaxis for chemotherapy related febrile neutropenia in an enrollee being treated for
myelodysplastic syndrome, a myeloid cancer. The Food and Drug Administration has not stated that the
requested drug is indicated for the enrollee's condition, The Medicare-approved cancer drug compendia do not
contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have
to pay for Fulphila (Q5108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided to the
enrollee on August 5, 2021.
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied
your request. The Plan says the service is not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code 81479 (1 Unit)
remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the
specimen was collected on July 20, 2021, and received by the lab on July 21, 2021; therefore, the billed code
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider.
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code 81479) provided
to the enrollee on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 28, 
2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was billed with an invalid place 
of service code. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code G0483 is not supported in the record. Specifically, this claim was billed with the 
laboratory place of service code while the records suggest that the member's face-to-face service was rendered 
in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing 
services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services (G0483) provided on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
head provided on September 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you feel that you are being billed for 
excess charges and the Plan paid nothing. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 $180 
copayment for advanced imaging services provided at a PCP or specialist office, or a free-standing radiological 
clinic.  
 You have been asked to pay $111.46, which is less than the $180 copayment for the CT scan. Please note that 
copayments and coinsurance are applied before the Plan covers their share. In this case, the amount charged 
was less than the copayment. The CT scan falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies 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 computed 
tomography (CT) scan of the head provided on September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the adult sized disposable incontinence product, 
brief/diaper, small, each (T4521). 
 
You asked the Plan to pre-approve incontinence supplies. You say that for many reasons, the enrollee needs the 
adult diaper but is unable to afford the cost. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the adult sized disposable 
incontinence product, brief/diaper, small, each (T4521).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical pathology, gross and microscopic examination 
(88305) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve surgical pathology, gross and microscopic examination. You say that you 
are appealing. The Plan denied your request. The Plan says there is an in-network laboratory that is able to 
provide the requested service and your plan does not include out-of-network coverage. 
 
  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 provider. 
 
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 
surgical pathology, gross and microscopic examination (88305) to be provided by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CGP testing (CPT code(s): 81201, 81295, 81298, 81317, 
81432) provided on September 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. 
 
Review of the available records presented for an appeal of molecular genetic pathology testing has been 
completed. After reassessing the entire situation, the result is that the initial denial is upheld. As CGP testing is 
not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described by any existing 
CPT code; to report a Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by 
MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, 
service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-test panel) at 
this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the 
test; not unbundled to separate codes, or other unlisted code. Therefore, we decided that the Plan does not have 
to pay for CGP testing (CPT code(s): 81201, 81295, 81298, 81317, 81432) provided on September 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services provided on March 23, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no other appropriate diagnosis. The 
Plan denied your request. The Plan says the code is not a benefit for the diagnosis listed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 88120 is not supported in the medical record. Specifically, the records do not hos that 
the testing was ordered by the enrollees treating physician for a specific medical problem. The testing is not 
covered for screening purposes. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the 
cytopathology services provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on
January 15, 2021, to June 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you were told these doctors were in
network and now you are told they are not. You are not able to pay this cost and do not feel you should have to
pay. The Plan denied your request. The Plan says enrollee's must receive their medical services from an innetwork provider with the exception being urgent or emergent services. Non-emergent services with noncontracted providers require prior authorization before services being rendered.
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 individual psychotherapy services (90832)
provided on January 15, 2021, to June 16, 2021, by an out-of-network (OON) provider.