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

 
We decided that the Plan does not have to pay for the office visit and debridement of nails provided on July 27, 
2021, by an out-of-network (OON) podiatrist. 
 
You asked the Plan to pay for office visit and debridement. The Plan denied your request. The Plan says the 
services were provided out-of-network and 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 the office visit and debridement of nails provided 
on July 27, 2021, by an out-of-network (OON) podiatrist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology services (81479) provided 
June 9, 2021 to October 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you feel that these claims should be covered 
because other claims were covered from 01/21/21 to 05/10/21 and you were not made aware that the claims 
after 5/10/21 would not be covered. The Plan denied your request. The Plan says the enrollee did not meet 
coverage requirements listed in the LCD. 
 
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 based on the medical records provided there is inadequate documentation to meet the 
medical necessity requirements for Medicare coverage of the unlisted molecular pathology testing (81479) 
provided from 06/09/2021 to 10/10/2021. The only provided records are a test result and an unsigned 
handwritten note that the enrollee is enrolled in a study (Prospera study). There are no other medical records 
supporting medical necessity of the testing have been provided to this reviewer.  
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 the unlisted molecular pathology services (81479) provided June 9, 2021 to October 
10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
December 7, 2021. 
 You asked the Plan to pay for the emergency department visit. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 99285 
is a column II code to column I code 99291. 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 the emergency department visit coded 99285 provided on 
December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay on March 5, 2021 
to March 10, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told this 
would be paid for by the plan. The Plan denied your request. The Plan says the cost share applied is correct. 
 
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 $315 
copayment per day, days 1-5; $0 per day, days 6-90 for an inpatient hospital stay. The total cost share owed is 
$1,575. 
 
You have been asked to pay a $315 copayment per day, days 1-5; $0 per day, days 6-90 for an inpatient 
hospital stay. An inpatient hospital stay 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 an inpatient hospital stay on March 5, 2021 to March 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has a right to choose the doctor to 
provide good service. The Plan denied your request. The Plan says there are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Decision Dx - squamous cell carcinoma (SCC) testing provided on 
January 4, 2022. 
 
You asked the Plan to pay for the Decision Dx - SCC testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the services rendered were not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the Decision Dx - SCC testing. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was high risk squamous cell carcinoma of the face. Decision Dx-SCC 
demonstrates a high degree of analytical precision, yielding high concordance rates across multiple 
performance experiments, along with exhibiting robust technical reliability on clinical samples. Therefore, the 
enrollee met criteria for the services rendered. 
 
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 Decision Dx - SCC testing have been met. Therefore, we decided that the 
Plan has to pay for the Decision Dx - squamous cell carcinoma (SCC) testing provided on January 4, 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve scaling and root planing (D4341) provided by a participating 
provider. 
 
You asked the Plan to pre-approve scaling and root planing. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that these services are not medically necessary. 
 
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 scaling and 
root planing when the services are medically necessary and reasonable. 
 
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 scaling and root planing. Our reviewer 
says that D4341 is medically necessary. Our physician reviewer found the criteria for coverage for scaling and 
root planing (D4341) in the upper left and lower left quadrant has been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of scaling and root planing have been met. Therefore, we decided that the Plan has 
to pre-approve scaling and root planing (D4341) provided by a participating provider.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve direct skilled nursing services of a RN in the home 
health or hospice setting, each 15 minutes (CPT code G0299 x1) and services performed by a qualified 
occupational therapist in the home health or hospice setting, each 15 minutes (CPT code G0152 x6). 
 
You asked the Plan to pre-approve the home health services. You say that you live alone and are not able to do 
your daily activities at home due to your right upper extremity injury. The Plan denied your request. The Plan 
says the services are not necessary. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our physician 
reviewer found the documentation does not support that you require in-home skilled nursing services or skilled 
rehabilitation services to provide treatment that is medically necessary. The documentation does not support 
that you are homebound. You have been medically stable without any recent exacerbations of chronic medical 
problems or hospitalizations. The requested home health services are not medically necessary as you can 
receive services on an outpatient basis. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve direct skilled nursing services of a RN in the home health or hospice setting, each 
15 minutes (CPT code G0299 x1) and services performed by a qualified occupational therapist in the home 
health or hospice setting, each 15 minutes (CPT code G0152 x6).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Venclexta. 
 
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 Venclexta.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee continues to have a need for skilled therapy; however, the documentation does not support that the enrollee 
would require an acute inpatient rehabilitation stay. The enrollee can receive further services at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance services (A0431-II, A0436-II) provided on 
July 16, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that you would like this claim reprocessed 
for payment based on the medical records. The Plan denied your request. The Plan says this claim has not been 
billed appropriately as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that air ambulance services may be paid only for ambulance services to a hospital. 
 
We looked at the file and Medicare rules. In this case, the claim reveals that the air ambulance services were 
billed with modifiers indicating that transport was provided from site of transfer to site of transfer. Payment 
cannot be made for air ambulance services with a destination anywhere other than a hospital. In addition, the 
documentation does reveal the air ambulances destination was a hospital. These services have been billed with 
an inappropriate modifier and payment cannot be made. Based on this information, we decided that Medicare 
rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for the air ambulance services (A0431-II, A0436-II) provided on July 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you want admission to IRF because you were 
independent before hospitalization and want to return to being independent. The Plan denied your request. The 
Plan says you do not meet the criteria for approval of IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you were admitted to an acute hospital on 6/28/22 with generalized weakness, 
rhabdomyolysis, and positive COVID-19 one week ago. You are medically stable. While you have a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
Your rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be adequately cared 
for in their current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting. The Plan has approved ongoing care in the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing the denial.  The Plan denied your 
request. The Plan says you do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 
 Our physician reviewer found you were admitted for a urinary tract infection and cellulitis. Medical problems 
are stable. Our physician reviewer found there are no complex nursing or rehabilitation needs. While you have 
a need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rabeprazole 20MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Rabeprazole 20MG tablet is a self-administered drug and does not fall under Part B 
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 Rabeprazole 20MG tablet.   
Benefits for the medication 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Oxycodone is a self-administered drug and does not fall under Part B 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 Oxycodone 10MG tablet.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.