Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on November 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that the facility is in-network, and the enrollee 
was seen by out-of-network physicians while in the facility. You say you rely on the facility to obtain the 
authorization. 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 
home health services. We found no exception that would require the Plan to pay for the home health services. 
The records provided for review do not show that the home health services were urgent or emergent. 
Therefore, we decided that the Plan does not have to pay for home health services provided on November 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chronic care management services provided on December 
31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that the facility requested the 
services. You say there is a medical necessity pre-established with the enrollee and the facility to provide the 
services. 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 
chronic care management services. We found no exception that would require the Plan to pay for chronic care 
management services. The records provided for review do not show that the chronic care management services 
were urgent or emergent. Therefore, we decided that the Plan does not have to pay for chronic care 
management services provided on December 31, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care and services. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary as you are unable 
to care for the enrollee because you are disabled yourself and there is no other family around to help. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for SNF care and her needs are custodial 
as she is functioning at supervision level. 
 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 daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (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 and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supply, provided on 
November 20, 2022. 
 
You asked the Plan to pay for the CGM supply. You say that the item should be covered. The Plan denied your 
request. The Plan says a proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (CGM) supply, provided on November 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on January 
31, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan. 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 
CT scan. We found no exception that would require the Plan to pay for the CT scan. The records provided for 
review do not show that the CT scan was urgent or emergent. Therefore, we decided that the Plan does not 
have to pay for the computed tomography (CT) scan provided on January 31, 2022, by an out-of-network 
(OON) provider.
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 LTACH services. You say that LTACH admission is medically necessary as 
the complexity of care exceeds SNF capability. The Plan denied your request. The Plan says the enrollee is 
receiving appropriate inpatient care at the current hospital and can remain there until ready for discharge to a 
lower level of care. 
 
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 that the enrollee does not require services at the LTACH that are not already 
available at the current 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 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 are medically stable and do not need PM&R physician close supervision 3 times 
per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. At the current functional level, you need SNF rehab and do not require 3 hours a day five days a 
week of IRF therapies with interdisciplinary management. Your rehab needs can be provided in an alternate 
and low intensity 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound coded 76706 provided on October 26, 2021. 
 You asked the Plan to pay for the ultrasound. 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 76706 
is a column II code to column I code 93976. 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 ultrasound coded 76706 provided on October 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided 
on January 11, 2022. 
 
You asked the Plan to pay for ultrasonic guidance for needle placement. You say that this service is supported 
in the medical record. The Plan denied your request. The Plan says a National Correct Coding Initiatives 
(NCCI) Procedure to Procedure (PTP) edit exists between 36556 and 76942. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was 
not billed with this PTP code edit. This service was not billed appropriately 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. In this case, we have confirmed that code 76942 
is a column II code to column I code 36556. 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 ultrasonic guidance for needle placement (76942) provided on 
January 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 18, 2021. 
 You asked the Plan to pay for the genetic testing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says screening services are not a covered benefit. 
 
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services provided on November 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6531, 
A6532, and A6545. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need these stockings due to 
your condition of lymphedema. The Plan denied your request. The Plan says the denial of authorization for 
these supplies is correct, because you do not have a qualifying wound for coverage of these compression 
stockings. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531, 
A6532, and A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules 
also say that compression bandages and gradient compression wraps are covered only when they are used as 
dressings over a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with codes 
A6531, A6532, and A6545.
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 IRF care is medically necessary to ensure the 
enrollee's safety and mobility. The Plan denied your request. The Plan says IRF care is not medically necessary 
and records show that it is not reasonable to expect the enrollee to fully benefit from the intensity of IRF 
services. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay provided on December 8, 
2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic Assay. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
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 GeneSight Psychotropic Assay at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. In addition, the documentation shows that the 
assay results were reported on December 17, 2021 and the order for the test was signed on January 6, 2022. 
This means that the order for the test was signed after the testing was completed. Therefore, we decided that the 
Plan does not have to pay for the GeneSight Psychotropic Assay provided on December 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bariatric surgery revision to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve the bariatric surgery revision. You say that the surgery was originally 
scheduled with an in-network provider, but that provider left and recommended an out-of-network provider. 
The Plan denied your request. The Plan says the requested provider is an OON provider and there are in-
network providers that provide the same quality of service. Also, the service requested is not emergent and the 
enrollee can safely transition to an in-network surgeon. 
 
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 bariatric surgery revision to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a diagnostic mammogram and breast 
tomosynthesis provided on September 8, 2021. 
 
You asked the Plan to waive the coinsurance for a diagnostic mammogram and breast tomosynthesis. You say 
that this was for your yearly preventive mammogram and needed additional testing because the images were 
unclear. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 20% 
coinsurance for in-network x-rays.  
 The medical record shows you had a diagnostic mammogram on September 8, 2021. Therefore, a cost sharing 
amount applies. You have been asked to pay $8.35, which is 20% coinsurance of the allowed amount for a 
diagnostic mammogram ($41.76 allowed amount x 20% coinsurance = $8.35). You have also been asked to 
pay $6.30, which is 20% coinsurance of the allowed amount for breast tomosynthesis ($31.50 allowed amount 
x 20% coinsurance = $6.30). You have been asked to pay a total of $14.65 ($8.35 coinsurance + $6.30 
coinsurance = $14.65). A diagnostic mammogram and breast tomosynthesis fall within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 coinsurance for a diagnostic mammogram and breast tomosynthesis provided on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have pre-approve a skilled nursing facility (SNF) admission.  
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says skilled 
nursing facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from December 19, 2021, to 
April 29, 2022. The Plan has covered 100 days of SNF care.  
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have pre-approve a skilled nursing facility (SNF) admission. pre-approve a skilled nursing 
facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the rendering provider sends the specimen 
to your laboratory to test, and you would like reconsideration on paying the claim. The Plan denied your 
request. The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on January 6, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest radiologic exam (x-ray) (71045), provided on 
November 24, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the service should be covered. The Plan denied your 
request. The Plan says the records submitted do not indicate that two separate services were 
performed/supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 the chest radiologic exam (x-ray) 
(71045), provided on November 24, 2021. have been met. The records submitted do not indicate that two 
separate services were performed/supported. Therefore, we decided that the Plan does not have to pay for the 
chest radiologic exam (x-ray) (71045), provided on November 24, 2021.