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

 
We decided that the Plan does not have to pay for the cardiovascular disease genetic risk panel provided on 
August 4, 2021. 
 You asked the Plan to pay for the cardiovascular disease genetic risk panel. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says these are not among the limited testing covered 
for cardiovascular disease screening. 
 
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 documentation does not reveal any signs/symptoms of cardiovascular disease. As such, this is considered 
noncovered screening testing. Therefore, we decided that the Plan does not have to pay for the cardiovascular 
disease genetic risk panel provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic respiratory pathogen panel testing for 22 targets 
provided on September 25, 2021, billed with code 0202U. 
 
You asked the Plan to pay for the 22-target panel. You say that this testing should be paid. The Plan denied 
your request. The Plan says this is noncovered testing. 
 
The Plan must follow Medicare rules. Medicare rules say that respiratory pathogen panels are covered for tests 
that target no more than five pathogens.   
 
We looked at the file and Medicare rules. The testing in this case tests for 22 pathogens, which is not covered. 
Based on this information, we decided that Medicare rules for coverage of the 22 target panel have not been 
met. Therefore, we decided that the Plan does not have to pay for the genetic respiratory pathogen panel testing 
for 22 targets provided on September 25, 2021, billed with code 0202U.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the speech therapy services provided between August 12, 
2021, and September 2, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON speech therapy services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says these services were not emergent and were provided 
OON without 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 the speech therapy services provided between 
August 12, 2021, and September 2, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 14, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON psychotherapy services. You say that this was medically necessary 
care. The Plan denied your request. The Plan says there was no authorization obtained for these non-emergency 
OON 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 the psychotherapy services provided on February 
14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 9, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you were not aware authorization was required. The 
Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior 
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 the nursing facility care provided on January 9, 
2022 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from May 18, 2020 
to July 1, 2020. 
 
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 claim was processed correctly. 
 
The Plan must follow Medicare rules. The rules say that all items and nonphysician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements.  
 
We looked at the file and Medicare rules. The file shows that the Plan reprocessed the claim and covered all 
services billed under the inpatient hospital coverage. Further services are not covered. 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 inpatient hospital services rendered from May 18, 2020 to 
July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on December 
21, 2021. 
 
You asked the Plan to provide reimbursement for the eyeglasses. You say that you were not aware that you 
would have to pay out of pocket for this, and when you did you believed you would be fully reimbursed. The 
Plan denied your request. The Plan says the record shows that the $175 benefit was applied to the purchase, 
with the $97 being your responsibility. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear. The contract with the Plan says that two pairs of eyeglasses are covered per year, with up to $175 
allowance for each pair.  
In this case, the maximum $175 allowance was applied at the time of purchase. You were asked to pay only the 
charges above this amount. Therefore, we decided that the Plan does not have to provide reimbursement for the 
eyeglasses purchased on December 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Coronavirus vaccine provided on September 23, 2021. 
 
You asked the Plan to pay for the Coronavirus vaccine. 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 by the Plan. 
 
The Coronavirus vaccine is to be billed directly to Original Medicare by the rendering pharmacy or physician's 
office. The Plan follows the same rules. Please submit this claim to Original Medicare for payment 
consideration. Therefore, we decided that the Plan does not have to pay for the Coronavirus vaccine provided 
on September 23, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the BRCA 1/2 genetic analysis provided on November 16, 2021, billed 
with code 81162. 
 
You asked the Plan to pay for the BRCA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says that no test results were submitted to support the billing of this code. 
 
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's rationale for denial is that the lab results of this testing were not 
submitted for review to justify payment. However, review of the file shows that the provider included both the 
test results and the requisition form for this testing. We find that the denial is not substantiated. Therefore, we 
decided that the Plan has to pay for the BRCA 1/2 genetic analysis provided on November 16, 2021, billed with 
code 81162.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on February 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed with this code edit. 
 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 75746 
is a column II code to column I code 37184. 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 imaging services provided to the enrollee on February 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sacroiliac joint radiofrequency ablation provided to the 
enrollee on June 28, 2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says services cannot be experimental or investigational to be covered. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered experimental/investigational because of the wide variation in efficacy reported in the 
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 pay for sacroiliac joint radiofrequency ablation provided to the enrollee on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 8, 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 lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
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. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 8, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the Electrocardiogram, routine ECG (93005) provided on December 
17, 2021. 
 
You asked the Plan to pay for code 93005. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the services are not covered. 
 
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 denied payment for code 93005 stating the status indicator assigned to 
this code is N and services are packaged in Ambulatory Payment Classifications (APC) Rates. However, for 
the date of service at issue in this appeal, the status indicator is Q1(S). As the Plan only provided this reasoning 
for their denial of payment, we find that the Plan has not supported its denial. Therefore, we decided that the 
Plan has to pay for the Electrocardiogram, routine ECG (93005) provided on December 17, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from January 1, 2022, 
to January 6, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says self-administered drugs are not covered 
under your Medicare Part B benefit. 
 
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 pay for the self-administered drugs 
provided from January 1, 2022, to January 6, 2022.   
Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after June 
22, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that you recently had an amputation and 
cannot walk.  You said that you need continued therapy to learn to walk. The Plan denied your request. The 
Plan says you are medically stable and continued SNF care is not medically necessary. 
 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 continued SNF care. Our reviewer says 
that continued SNF care is not medically necessary. Our physician reviewer found at the time of admission, 
you required skilled rehab services to improve function due to weakness and deconditioning. There were no 
skilled nursing needs. As of June 22, 2022, you did not require any skilled nursing or rehab services on a daily 
basis. You were not expected to make measurable gains within a reasonable and predictable period of time or 
require skilled therapy to prevent deterioration with mobility. You did not require skilled therapy to establish a 
safe and effective maintenance program. As a practical matter, you did not require any skilled services on an 
inpatient basis, at a SNF level of care as of June 22, 2022. You did not have any parental medications, complex 
wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your 
functional improvement had plateaued by June 22, 2022, and you did not require any further inpatient skilled 
rehab services. Your function was at or near your prior level of function and you could be discharged to a lower 
level of care for further 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after June 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on February 8, 2022. 
 
You asked the Plan to pay for these services. You say that there was no dentist in your area and you had an 
infection causing pain, so you went to see your primary doctor. The Plan denied your request. The Plan says 
the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers supplemental 
dental benefits from a dental provider. 
 
We looked at this the file and Medicare rules. The file shows that the routine dental services were performed by 
a primary care physician. These services are not covered by your medical benefit. The services are not covered 
by your supplemental dental benefit because they were not performed by a network dentist. Based on this 
information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the office visit rendered on February 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on June 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records do not contain documentation of definitive laboratory results for 22 or more 
drug classes, including metabolites to support the coding criteria for G0483 for the billed date of service 
06/10/2021. 
 
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 G0483 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the medical records only support that 
15 drug classes were tested in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on June 10, 2021.
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 SNF care is medically necessary for the beneficiary. 
The Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 SNF 
care is not medically necessary. Our physician reviewer found the beneficiary has no identifiable skilled 
nursing needs.  Although the beneficiary has skilled therapy needs, he does not require this care on a daily basis 
in an inpatient SNF setting. 
 
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.