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

 
We decided that the Plan does not have to pay for immunoassay for tumor antigen (86304, 86300, 86301) 
carcinoembryonic Antigen (82378) homocysteine (83090) alpha-fetoprotein, serum (82105) cyanocobalamin 
(vitamin B-12) (82607) folic acid, serum (82746) provided July 16, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the testing was ordered by an in-network 
physician to evaluate and determine effective treatment planning for the enrollee. The Plan denied your request. 
The Plan says screening services such as pre-symptomatic genetic tests and services used to detect an 
undiagnosed disease or disease predisposition are not a benefit and are not covered. 
 
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 test at issue in this appeal, the laboratory services, 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 immunoassay for tumor antigen (86304, 86300, 86301) carcinoembryonic Antigen (82378) homocysteine 
(83090) alpha-fetoprotein, serum (82105) cyanocobalamin (vitamin B-12) (82607) folic acid, serum (82746) 
provided July 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services 
provided from November 8, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayment for the SNF services. You say that the services should be covered 
as you disagree with the charges. 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). Your contract with the Plan clearly says that you must pay a $20 
copayment per day for days 1-20 and a $100 copayment per day for days 21-44 of for Skilled nursing facility 
(SNF) care.  
 You have been asked to pay a $400 copayment for days 1-20 of SNF care and a $300 copayment for days 21-
23 of SNF care. 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 skilled nursing facility (SNF) 
services provided from November 8, 2021, to November 30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 15, 2021, to May 
17, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and are supported in the record. Providing this care in an outpatient setting could have been 
detrimental for the enrollee. The Plan denied your request. The Plan says that the services provided on the dates 
in question were outpatient services rather than inpatient services, and the inpatient hospital care billed was not 
medically necessary and is not supported in the record. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee with a medical history of cerebral palsy presented as a transfer to the 
emergency department (ED) from an outside facility on May 15, 2021, for evaluation of a peritonsillar abscess. 
There was no documentation of difficulty with swallowing or breathing. On arrival, his exam showed bilateral 
soft tissue swelling over the soft palate with no drooling or stridor. Imaging showed right and left peritonsillar 
abscess and reactive cervical lymphadenopathy. The enrollee was admitted as an inpatient with a plan of care 
that included antibiotics, steroids, and nothing by mouth overnight. The following day, he had an incision and 
drainage of the abscesses with no documented complications. His vitals improved, and he was discharged home 
on May 17, 2021, in hemodynamically stable condition. The review has determined that the record showed that 
at the time of inpatient admission the admitting physician reasonably expected that the enrollees necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 15, 2021, to May 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided October 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that due to the expansive clinical value of the 
testing you do that benefits the enrollee, you ask for reconsideration of the denial and request payment in full 
for the testing. The Plan denied your request. The Plan says the documentation does not support that the 
services rendered were 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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. 
 Our physician reviewer found the review indicates that the medical record sent by the provider shows a 
definitive UDT panel for multiple drug classes was performed, but does not show screening test results which 
are positive or inconsistent with prescription medications, dosing schedules, or history and expected results. 
Clinicians should not test for substances when the results would not affect patient management, or for which 
implications for patient management are unclear. Each individual definitive drug class tested must be medically 
necessary, and the results of each drug class tested must be used to treat an active illness or disease, as opposed 
to being used for screening purposes. Ordering a multi-drug panel of definitive (confirmation) urine drug tests 
that are not used in management of the member is not medically necessary. The review has determined that the 
medical records provided do not meet the requirements listed in the LCD for Medicare 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 the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for definitive urine drug testing (UDT) for 22 or more drug classes (G0483) provided 
October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
18, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 18, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
21, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 21, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 
15, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 15, 
2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for Home Health services provided on May 6, 2021, through June 2, 2021. 
 
You asked the Plan to pay for the Home Health services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this claim was not billed correctly. 
 
`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. Specifically, the Plan has not forwarded any evidence to support why this claim 
was billed incorrectly. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, 
the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan 
has to pay for Home Health services provided on May 6, 2021, through June 2, 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 administration of a pneumococcal vaccine (G0009), the 
annual wellness visit (G0438), and the pneumococcal polysaccharide vaccine (90732) rendered by the out-of-
network (OON) provider on July 26, 2021. 
 
You asked the Plan to pay for the item/services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the item/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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the item/services at issue in this appeal. The Plan did not pre-approve the 
item/services at issue. We found no exception that would require the Plan to pay for the item/services. 
Therefore, we decided that the Plan does not have to pay for the administration of a pneumococcal vaccine 
(G0009), the annual wellness visit (G0438), and the pneumococcal polysaccharide vaccine (90732) rendered by 
the out-of-network (OON) provider on July 26, 2021.
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 December 1, 2020, to December 26, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 clinical documentation does not 
support metabolic encephalopathy as an active diagnosis for the time frame in question. There are limited 
records for the look-back period to confirm a PT/OT and nursing function score of 0-5. The records do not 
support the presence of tube feeding with 26-50% caloric intake, and 501cc or greater of fluids. The records do 
not consistently support cognitive impairment. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from December 1, 2020, to 
December 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (82310, 83540, 83550, 84100) provided 
on July 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that there is no contractual agreement to include 
these services in the dialysis. The Plan denied your request. The Plan says these services are not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that all laboratory services furnished to individuals 
for the treatment of end-stage renal disease (ESRD) are included in the ESRD Prospective Payment System 
(PPS) as Part B services and are not paid separately. 
 
We looked at the file and Medicare rules. The laboratory services at issue were provided for the treatment of 
ESRD. Based on this information, we decided that Medicare rules for coverage of laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82310, 83540, 
83550, 84100) provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses lenses (V2100, V2799) purchased on 
November 27, 2021. 
 You asked the Plan to pay for the eyeglass lenses. You say that this was just your general yearly eye exam, and 
you only replaced the lenses in your current eyeglass frames. The Plan denied your request. The Plan says you 
previously received routine eyewear in November 2020, which is less than two years before the date in 
question. You are covered for one pair of lenses and frames every 2 years, so the lenses provided on November 
27, 2021, exceeded the frequency limitation of your benefit. 
 
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 once every two years. 
 
We looked at the file and the Plan's rules. The record shows that you last used your routine eyewear benefit less 
than two years before the date in question. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglass lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
the eyeglasses lenses (V2100, V2799) purchased on November 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the eye exam (92014, 92015) provided on 
October 8, 2021. 
 
You asked the Plan to waive the cost-share for the eye exam. You say that you met your deductible, and do not 
understand why this procedure is not covered. The Plan denied your request. The Plan says this claim was 
processed correctly, and your deductible and copayment were applied in accordance with your contract. You 
had not met your deductible prior to the date in question, but the deductible was met with these services. In 
addition, you are responsible for a $10 copayment for each Medicare-covered eye exam. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to Medicare-covered eye exams.  
 
The item or service you asked the Plan to waive the cost-share for falls within the Medicare-covered eye exams 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to Medicare-covered eye exams. This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on 
October 8, 2021. The documentation supports that you met your deductible during this claim and were asked to 
pay only the remaining amount of the deductible and your $10 copayment for the eye exam. The Plan covered 
the remaining cost. This means 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 cost-share for the eye exam (92014, 92015) provided on 
October 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428) and ground mileage (A0425) provided October 21, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance services and ground mileage. You say that the 
transport was medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained for the transport and therefore the services are not covered. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
contract says that prior authorization is required for non-emergent ambulance services.  
 
We looked at the file and Medicare rules. In this case the non-emergency transport was provided to the enrollee 
without prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-
emergency ambulance services and ground mileage have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and 
ground mileage (A0425) provided October 21, 2021.
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 facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says you do not meet the Medicare LCD coverage criteria 
for facet joint injections. 
 
The Plan follows Medicare rules.  
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found the next step is RFA not 
repeated diagnostic injection. The request is 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on February 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the domiciliary visit provided on February 4, 2021, by an out-of-
network (OON) provider.