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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from June 1, 2022, to June 12, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says during the time at issue in this case, the enrollee no longer clinically required daily 
skilled services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that based on the medical records provided there is no documentation that the patient 
required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a 
skilled professional nurse were not required to safely and effectively provide medically necessary and 
reasonable treatment from June 1, 2022 through June 12, 2022. The records did not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. 
The patient was walking household distances with no assistive device and was independent for transfers and 
was independent to supervision level for activities of daily living. The enrollee did not require the services on 
an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in 
this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) services provided to the enrollee from June 1, 2022, to June 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on June 14, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be covered. 
 
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 lab testing provided on June 14, 2022, by an out-
of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 1, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET); metabolic 
evaluation of the brain (78608). 
 
You asked the Plan to pre-approve a PET scan of the brain. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the medical records provided do not indicate that the enrollee meets the 
diagnostic criteria of both Alzheimer's disease and frontotemporal dementia. There is no indication that the 
exam is being requested in the context of a clinical trial. The request does not meet the Medicare or health plan 
coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a PET scan of the brain. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found according to the applicable 
NCD, PET/CT of the brain may be covered for individuals who meet diagnostic criteria for both AD and FTD 
(when additional requirements are met). The records provided for review indicated that the enrollee in this case 
has memory problems. However, there was no indication that either AD or FTD were suspected (let alone 
both). The enrollee is not noted to meet diagnostic criteria for both syndromes. The base criteria for coverage 
of this service as defined by the NCD would not be met. Therefore, this request would not be eligible for 
coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET); metabolic evaluation of the brain 
(78608).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor and Heme CGP Panel testing 
provided on December 17, 2021. 
 
You asked the Plan to pay for the Tempus gene panel. You say that this service was medically necessary. The 
Plan denied your request. The Plan says this testing is not FDA approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT and Heme CGP Panel testing are 
not FDA approved. Based on this information, we decided that Medicare rules for coverage of the requested 
testing have not been met. Based on this information, we decided that Medicare rules for coverage of the 
Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
Tempus xT Solid Tumor and Heme CGP Panel testing provided on December 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transport ambulance service and ground 
mileage provided on June 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for non-emergency transport ambulance service and ground mileage. You say that 
you have submitted records for transport. The Plan denied your request. The Plan says they require prior 
authorization per the EOC. 
 
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 non-emergency transport ambulance service and 
ground mileage provided on June 17, 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 anesthesia for diagnostic arteriography/venography provided 
on February 25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for anesthesia for diagnostic arteriography/venography. You say that the services are 
a necessary procedure in the member's care. 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 these services were not 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 anesthesia for diagnostic 
arteriography/venography provided on February 25, 2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from January 21, 2022, to 
March 21, 2022. 
 
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. The rules say that HHAs must send a Notice of Admission (NOA) to 
Medicare. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid NOA. 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 home health services rendered from January 
21, 2022, to March 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device and supplies rendered on May 26, 2022. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS is covered for CLBP that meets specific 
criteria when enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. The file shows that the services were not rendered as part of an 
approved clinical study. 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 transcutaneous 
electrical nerve stimulation (TENS) device and supplies rendered on May 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 87798 billed for date of service April 22, 
2022. 
 You asked the Plan to pay for procedure code 87798. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 87798 is 13. The MAI value for this code is 2. You billed 19 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 87798 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 87798 billed for date of service April 22, 2022.
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 admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 limited documentation provided, it is my opinion that you do not qualify 
for SNF coverage. You do not have documented skilled nursing needs or documented skilled therapy needs. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your 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 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 pay for a nursing facility care visit provided on May 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a nursing facility care visit. You say that you are requesting the claim denial be 
reviewed and reprocessed for payment. The Plan denied your request. The Plan says an authorization was not 
obtained prior to services 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 a nursing facility care visit provided on May 13, 
2022, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
February 2, 2022, to February 23, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the claim must be completed 
for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
procedure codes/type of bill is inconsistent with the place of service billed. This means the claim is not payable 
as billed. Therefore, we decided that the Plan does not have to pay for the home health services provided to the 
enrollee from February 2, 2022, to February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 81403, 81404, 81405, 81406, 
81407, 81408, and 81479 provided on February 25, 2021.  
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 81403, 81404, 81405, 81406, 81407, 81408, and 81479 provided on February 25, 
2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for chiropractic manipulative treatment received from April 1, 2022 to 
June 14, 2022. 
 
You asked the Plan to pay for the services. You say that you were not notified that there was a limit to these 
services. The Plan denied your request. The Plan says that the benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial in this case. The services provided 
were represented by Current Procedural Terminology (CPT) code 98942. This is a code that represents 
chiropractic manipulative treatment (CMT); spinal, 5 regions. The only Medicare-covered benefit for 
chiropractic services is manual manipulation of the spine to correct subluxation, which is what this code represents. 
 
Therefore, there should have been a $0 copayment for the various manipulative treatments received during this 
time period. Additionally, the Evidence of Coverage does not explicitly say that Medicare-covered chiropractic 
services are limited to 24 treatments per year. The benefit covered by traditional Florida Medicaid for office 
visits, limited to 24 per calendar year, appears under a separate heading. It is reasonable to assume that 
Medicare-covered services are not limited to 24 per year. Medicare does not provide a numeric limit for 
chiropractic manipulative treatments. Therefore, we decided that the Plan has to pay for chiropractic 
manipulative treatment received from April 1, 2022 to June 14, 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 a home health visit provided on June 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that you are not responsible to request an 
authorization for the service that was rendered. The Plan denied your request. The Plan says the rendering 
provider is an OON provider and there was no approved authorization. 
 
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 home health visit provided on June 1, 2022, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee should qualify for intradetrusor 
Botox due to their failure of behavioral modifications and multiple medications at multiple doses. The Plan 
denied your request. The Plan says the provided documentation does not show that the enrollee has tried and 
failed to get better from two other medications. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug is not medically reasonable or necessary. Our physician reviewer found that based on the 
medical records provided, there is no indication that the enrollee has tried and failed two anticholinergics. The 
enrollee has tried and failed one anticholinergic (oxybutynin) and one beta-3 adrenergic agonist 
(mirabegron). There is no indication that the plan's required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. 
 
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 Botox injections.