Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from October 24, 
2020, through October 31, 2020, and billed with a Patient Driven Payment Model (PDPM) score of OHXE1. 
 
You asked the Plan to pay for the SNF care as originally billed. You say that the claim has been appropriately 
billed and does not need to be reprocessed with a new PDPM score. The Plan denied your request. The Plan 
says that there is a more appropriate PDPM score that should have been billed for the services 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. In this case, the Plan has failed to forward any medical documentation regarding 
the services in question. Without any medical records, it is impossible to evaluate the Plans decision to 
reprocess the PDPM in question. The Plan specifically states, The facility provided nursing and therapy daily 
notes, the ADL grid (Documentation Survey Report) for October 2020 and an OT evaluation for October 25, 
2020. The case file we received included none of this information. Therefore, we decided that the Plan has to 
pay for the skilled nursing facility (SNF) services provided from October 24, 2020, through October 31, 2020, 
and billed with a Patient Driven Payment Model (PDPM) score of OHXE1.  
 
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 the laboratory services rendered on December 7, 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 are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on December 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospice room and board provided from October 1, 2021, to 
October 11, 2021. 
 
You asked the Plan to pay for hospice room and board. 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 hospice room and board provided from October 1, 2021, to 
October 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that documentation fails to indicate that you require therapy at the skilled 
nursing 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 pre-approve SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There are no identifiable skilled nursing or therapy 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity 
of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Our physician 
reviewer found that your condition does not meet Medicare criteria for continued SNF services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an administration of the influenza virus vaccine (G0008) and 
an Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen 
content, for intramuscular use (90662) provided on September 24, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an Influenza virus vaccine and administration. You say that you are requesting a 
reconsideration of the denied claim as it was billed incorrectly. The Plan denied your request. The Plan says 
you must use network providers to get your medical care and 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 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 administration of the influenza virus vaccine 
(G0008) and an Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via 
increased antigen content, for intramuscular use (90662) provided on September 24, 2021, 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 domiciliary visit provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the staff failed to take the proper steps on 
obtaining an authorization and you would like the claim paid. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benicar HCT for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Benicar HCT for the 
enrollee.  
 
Benefits for this drug 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) 
provided on November 6, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that you scratched a vein open. You say that the 
bleeding would not stop. You say that you felt this was an emergency situation. You also say that you would 
like this to be covered. The Plan denied your request. The Plan says since there was no transport provided, 
there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport, (A0998) provided on November 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the routine eyewear (V2744, V2799, 
A9270) provided February 3, 2022. 
 You asked the Plan to provide additional payment for the routine eyewear. You say that you were told you 
would be reimbursed $200. The Plan denied your request. The Plan says your $200 benefit was already applied 
to your eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to your $200 allowance every year. 
 
We looked at the file and the Plan's rules. The Plan provided documentation showing that your full $200 
allowance was applied to your routine eyewear purchased February 11, 2022. This means no further payment 
for routine eyewear is due. Therefore, we decided that the Plan does not have to provide additional payment for 
the routine eyewear (V2744, V2799, A9270) provided February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 4, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed without the appropriate modifier. 
 
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 payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the professional interpretation must be billed with 
modifier -26 for payment to be considered. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the 
lab services provided on February 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine ID panel coded as 87511, 87653, 87640, 87798, 
87481, 87500and 87641. 
 
You asked the Plan to pay for the laboratory service. You say that you dispute the determination because the 
services were medically necessary. The Plan denied your request. The Plan says the medical records provide 
did not substantiate the need for this expanded diagnostic exam 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record provided did not substantiate need for this expanded diagnostic 
exam. The reviewed records furnished only included a test requisition and results of said test for the indication 
of N390 - URINARY TRACT INFECTION, UNSPEFICIED without clinical notes to substantiate the need for 
this expanded test as opposed to other cost-effective measures. The review has determined that the 
items/services at issue in this case were 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the urine ID panel coded as 87511, 87653, 87640, 87798, 87481, 87500and 87641.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BCG (tice strain) 50 mg vial. 
 
You asked the Plan to pre-approve BCG 50 mg vial. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve BCG (tice strain) 50 mg 
vial.  
 
Benefits for BCG 50 mg vial 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 FoundationOne CDx (F1CDx) test (0037U) provided 
January 3, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 does not meet 
Medicare NCD/LCD criteria. 
 
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 laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence panel of 51 and greater genes 
(81455) provided September 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please review the following medical records 
to reconsider denial codes 81455 for medical necessity. The Plan denied your request. The Plan says this 
service does not meet Medicare requirements of the Plan benefits and is excluded from coverage. 
 
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. 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 targeted genomic sequence panel of 51 and greater genes (81455) provided September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant-at-surgery services provided on February 23, 2022. 
 
You asked the Plan to pay for assistant-at-surgery services. You say that you are appealing this denial. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is not eligible to provide assistant-at-surgery services. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for assistant-at-surgery services 
provided on February 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the injections. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications 
established in the applicable LCD. 
 
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 injections. Our reviewer says that 
the requested injections are not medically reasonable and necessary. Our physician reviewer found that in this 
case, there was not consistent relief from the first diagnostic facet joint block/MBB of at least 80% relief of 
primary (index) pain. The requested injections are not medically reasonable or necessary according to the LCD 
coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (81455) provided on December 9, 2021. 
 
You asked the Plan to pay for the genetic testing (81455). You say that the provided genetic testing was 
medically necessary. The Plan denied your request. The Plan says a panel of 51 or greater genes is not 
reasonable or 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 pay for the genetic testing (81455). Our reviewer 
says that the provided genetic testing is not reasonable or medically necessary. Our physician reviewer found 
based on the medical records provided there is no documentation that the genetic testing at issue in this case 
meets Local Coverage Determination (LCD): Biomarkers for Oncology (L35396) criteria for coverage. 
Provided records do not clearly document "how each requested biomarker can be individually contributory" to 
the enrollee's care as required by the LCD. 
 
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 genetic testing (81455) have not been met. Therefore, we decided that the 
Plan does not have to pay for the genetic testing (81455) provided on December 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 24, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that testing for biomarkers for oncology is covered for the 
indications established in the applicable LCD. 
 
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 testing. Our reviewer says that the 
requested testing is not medically reasonable and necessary. Our physician reviewer found that treatment is not 
dictated by actionable mutations. Treatment can be administered without molecular testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
March 13, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you feel the services were 
denied. 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 $200 per 
day for days 1-6 and $0 per day for days 7-90 for each inpatient admission.  
 
The file shows that you were in the hospital from March 13, 2022, to March 25, 2022. Therefore, you have 
been asked to pay $200 per day for days 1-6 of inpatient care. The total for your stay is $1,200 ($200 
copayment x 6 days = $1,200). The inpatient care falls within the Inpatient Hospital Care 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 inpatient hospital care provided from March 13, 2022, to 
March 25, 2022.