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

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 1, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. 
 The Plan denied your request. The Plan says this test was not billed in accordance with Medicare rules, as the 
required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are appealing, on behalf of the enrollee, the pre-
service denial of services in an inpatient rehabilitation facility. The Plan denied your request. The Plan says 
admission to IRF was denied as not meeting IRF criteria and is not medically necessary. The enrollee is not 
medically stable to transfer to another level of care. 
 
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 enrollee was admitted for chronic obstructive pulmonary disease 
exacerbation and was discharged on August 6, 2022. The enrollee has developed pressure ulcers since 
discharge and was evaluated in the emergency department for these on September 2, 2022 and discharged 
home.  Medical problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee 
has a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A4557 billed for date of service March 2, 
2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee has no control over the services 
required by the surgeon. The Plan denied your request. The Plan says procedure code A4557 is 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 procedure code. 
 
We find that procedure code A4557 is a bundled code. This means that procedure code A4557 is not separately 
payable. Based on this information, we decided that Medicare rules for coverage of the services provided have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code A4557 billed for 
date of service March 2, 2022.
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 the enrollee would benefit from IRF care. The Plan 
denied your request. The Plan says an IRF admission is not medically necessary. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the at-home coronavirus test purchased on January 
15, 2022. 
 
You asked the Plan to reimburse you for the at-home test. You say that you received a letter from your plan in 
regard to the reimbursement start date. You also say that the pharmacy advised of the start date of January 15, 
2022. The Plan denied your request. The Plan says coverage was not available on the date of service in this 
case. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home test have not been met. Specifically, plan documents clearly state that coverage was 
not available on the date of service in this case. Therefore, we decided that the Plan does not have to reimburse 
you for the at-home coronavirus test purchased on January 15, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve five physical therapy visits. We also decided that the Plan does not 
have to pre-approve seven physical therapy visits.  You asked the Plan to pre-approve therapy visits. You say that the enrollee has been improving with therapy 
treatments. The Plan denied your request. The Plan says that additional physical therapy is not medically 
necessary. 
 
We decided that the Plan has to pre-approve five physical therapy visits.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy visits. Our reviewer says that 
the coverage criteria for five therapy visits has been met. Our physician reviewer found the clinical 
documentation shows that patient has had functional setbacks due to falls with further injury and is making 
progress toward goals. The provider specifically asks for five additional physical therapy sessions which 
appears reasonable for listed goals due to further injury. Therefore, five additional physical therapy sessions are 
medically 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 therapy visits have been met. Therefore, we decided that the Plan has to pre-
approve five physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve seven physical therapy visits. 
 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the remaining seven physical 
therapy visits are not 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 seven therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven physical therapy visits.  
 
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient psychotherapy services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the outpatient psychotherapy services. You say that you would like to see 
the OON provider because your primary language is Spanish. The Plan denied your request. The Plan says the 
requested provider is an OON provider and there are multiple in-network providers who speak Spanish and can 
treat the enrollee. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the outpatient psychotherapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the shoe inserts because you are barely 
able to walk due to fallen arches. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the over-the-counter (OTC) coronavirus test kit purchased on 
April 29, 2021. 
 
You asked the Plan to pay for the OTC test. You say that it was required that you buy these tests so that you 
could fly back to the United States. You also say that this should be covered as a required Covid-19 test. The 
Plan denied your request. The Plan says the provider in this case is not a participating pharmacy. The Plan also 
says that Medicare cannot process a claim submitted by a beneficiary for an OTC coronavirus test. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the OTC 
test is an OTC item. Therefore, we decided that the Plan does not have to pay for the over-the-counter (OTC) 
coronavirus test kit purchased on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a BioWave device (E1399). 
 
You asked the Plan to pre-approve the BioWave device. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a BioWave device (E1399). have been 
met. No clinical records were provided to support the request. Therefore, we decided that the Plan does not 
have to pre-approve a BioWave device (E1399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from March 7, 2022, to April 5, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services were required and are covered under the 
Medicare Act. The Plan denied your request. The Plan says the enrollee no longer required daily skilled 
services on an inpatient basis. 
  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 the enrollee did not require skilled nursing services or skilled therapy services. In 
addition, the enrollee did not require services on an inpatient basis, only in a skilled nursing facility 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 pay for SNF care provided from March 7, 2022, to April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The 
Plan denied your request. The Plan says the records do not show that the enrollee's rehabilitation needs are 
complex and that they need to be seen by a rehabilitation doctor 3 times per week for evaluation of functional 
and medical goals and progress. The services the enrollee needs can be provided safely in other settings like a 
skilled nursing facility, home with home health services or home with outpatient therapy. 
 
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 that the enrollee is medically stable and does not need physical medicine and 
rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any 
active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs identified or 
documented. At the current functional mobility and medical status, the enrollee does not need intensive 
therapies consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach in an IRF. IRF admission is not medically necessary based lack of medical complexity and acute 
rehabilitation nursing needs. 
 
Documentation does not support the medical necessity for admission to an IRF. While the enrollee may benefit 
from continued physical therapy and occupational therapy, the enrollee's rehabilitation needs can be safely 
provided in a lower intensity and alternate setting such as in-home with 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the laboratory does not have 
a contract with the dialysis facility which indicates these services are included in the dialysis rate. The Plan 
denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
February 6, 2022. 
 
You asked the Plan to pay for procedure codes 99100 and 99140. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says procedure codes 99100 and 99140 are considered bundled 
and 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 procedure code. 
 
We find that procedure codes 99100 and 99140 have a status indicator of B on the Physician Fee Schedule. 
This means that procedure codes 99100 and 99140 are not separately payable. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99100 and 99140 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99100 and 99140 billed for date of service 
February 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are home by yourself and need the three hours 
per day of rehabilitation instead of one hour. You also say that you were an active person that wore a fitbit 
watch and you need to get back to where you were. The Plan denied your request. The Plan says based on 
Medicare guidelines, the inpatient rehabilitation facility IRF services you are requesting 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 surgical management of a hip fracture. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. While you have a need for physical or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the enrollee needs this test. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
We reviewed the file and the Medicare rules. We find that the medical records shows the enrollee only has a 10 pack-years history of tobacco smoking. Therefore, we decided that the Plan does not have to pre-approve a low 
dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prothrombin time laboratory test (85610) provided on April 
21, 2022. 
 
You asked the Plan to pay for a prothrombin time test. You say that the service at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. The rules specify the ICD-10-CM codes that are covered by the 
Medicare program.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a prothrombin time test have not been met. Specifically, the service at issue was billed with 
diagnosis codes that are not listed as covered by the Medicare program for this service. Therefore, we decided 
that the Plan does not have to pay for a prothrombin time laboratory test (85610) provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on  
October 8, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on October 8, 2021.