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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond December 3, 
2022. 
 
You asked the Plan to pre-approve SNF care. You say that it is felt that the enrollee would benefit from 
continued daily skilled care. The Plan denied your request. The Plan says there is no clinical evidence to 
support the medical necessity of this service or that the enrollee meets Medicare criteria for coverage. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not 
have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, custodial and 
intermittent, can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care beyond December 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Unlisted Molecular Pathology (81479) provided July 22, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that please find the appeal information that 
describes the medical necessity of the PrismRA test to inform consideration of payment. The Plan denied your 
request. The Plan says this service is not allowed based on Medicare guidelines. 
 
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 laboratory service have been met. Medical records were needed and requested from the supplier to support medical necessity of the services. The 
Plan made multiple attempts to obtain medical records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for Unlisted Molecular Pathology (81479) provided July 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the 
enrollee on August 5, 2021. 
 
You asked the Plan to pay for the services. You say that presumptive urine drug testing for all twenty-two 
classes of opioids is necessary for each of our pain patients in order to prevent over prescribing opioids and to 
confirm patients are not abusing street drugs while taking their opioid prescriptions. The Plan denied your 
request. The Plan says the number of drug classes tested should reflect only those likely to be present based on 
the medical history, current clinical presentation, and the illicit drugs that are in common use. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that just prior to this testing, a screening presumptive urine drug test was consistent with prescriptions 
except for there was no evidence of Pregabalin use over the prior 24 hours; however, the patient reported not 
using it very often. The urine screening did not reveal any other unexpected results. Nor was there any 
indication in the history suggesting drug misuse/abuse to justify definitive drug testing, particularly for many 
drug classes not pertinent or applicable to this patient. Therefore, based on the provided documentation and the 
standard of care, the enrollee did not need 22+ classes of drugs tested in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services (procedure code G0483) provided to the enrollee on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to stand or walk on your own. The 
Plan denied your request. The Plan says there is no need for an intensive rehabilitation program. 
 
The Plan must follow Medicare rules. The rules say that an 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 your medical problems are stable, and you have no complex nursing or 
rehabilitation needs. While you may need physical and/or occupational therapy, there is no documented need 
for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
 There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided February 15, 2022, to 
March 16, 2022. 
 
You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan follows Medicare rules. The rules say that the claim and NOA must have correct information in order 
to process. 
 
Review of the file shows that the final claim has an admit date of December 17, 2021. A valid NOA was not 
provided for the February 15, 2022, to March 16, 2022 home health claim submitted. As the claim and NOA 
have incorrect information, no payment can be made on this claim. Therefore, we decided that the Plan does 
not have to pay for the home health services provided February 15, 2022, to March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29881 billed for date of service June 13, 
2022. 
 
You asked the Plan to pay for procedure code 29881. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 29881 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29881 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29881 billed for date of service June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 27, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that the facility was not aware that authorization was 
required. The Plan denied your request. The Plan says authorization was not obtained prior to services being 
rendered, and the referring provider is also not a network provider. 
 
  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 office visit. Our reviewer says that the 
records do not indicate that the care provided was medically necessary. Our physician reviewer found the 
enrollee had known chronic osteomyelitis of the heels and had undergone full evaluation with MRI, laboratory 
studies and treatment with antibiotics. It would have been medically reasonable to delay the services until when 
the enrollee returned to his/her service area. 
 
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 office visit have not been met. Therefore, we decided that the Plan does not 
have to pay for an office visit provided on April 27, 2022, by an out-of-network provider.
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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 was admitted for aortic valve replacement. Medical problems are stable. There are no complex nursing or 
rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/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 inpatient rehabilitation facility (IRF) admission and services.
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 it is not safe or practical for you to rehabilitate at 
home in your present condition. You say you need 24-hour care following back surgery and you are a fall risk 
to go home. The Plan denied your request. The Plan says the 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 the complexity of your nursing, medical and rehabilitation needs do not require 
an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You continue to 
have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement 
however, the documentation doesnt support that you meet criteria for admission to an acute inpatient 
rehabilitation facility. You 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for a filling. We decided that the Plan does not have to pay for a 
prefabricated stainless-steel crown.  
 
You asked the Plan to pay for a filling (D2330), and a prefabricated stainless-steel crown (D2931) provided on 
May 25, 2022.. You say that you want the Plan to pay for the services. The Plan says that the prefabricated 
stainless-steel crown is not a covered benefit. 
 
We decided that the Plan has to pay for a filling.  
 
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 for the filling. The Plan has not provided any valid justification 
for any portion of the filling to be charged to you. Therefore, we decided that the Plan has to pay for a filling.  
 
We also decided that the Plan does not have to pay for a prefabricated stainless-steel crown. 
 
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. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the prefabricated stainless-steel crown is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for a prefabricated 
stainless-steel crown. 
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950), and a porcelain/ceramic (D6740) for tooth number 21. 
 
You asked the Plan to pre-approve core buildup, including any pins when required (D2950), and a 
porcelain/ceramic (D6740) for tooth number 21. You say that this does not meet criteria. The Plan denied your 
request. The Plan says the documentation provided does not support the need for a core buildup and 
replacement crown for tooth number 21. 
 
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 core buildup, 
including any pins when required (D2950), and a porcelain/ceramic (D6740) for tooth number 21 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 core buildup, including any pins when 
required (D2950), and a porcelain/ceramic (D6740) for tooth number 21. Our reviewer says that the service is 
not medically necessary. Our physician reviewer found that the documentation provided does not support the 
need for a core buildup and replacement for tooth number 21. 
 
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 core buildup, including any pins when required (D2950), and a 
porcelain/ceramic (D6740) for tooth number 21 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve core buildup, including any pins when required (D2950), and a porcelain/ceramic 
(D6740) for tooth number 21.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from March 19, 2022, to March 
21, 2022. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to show 
the necessity of these services. The Plan denied your request. The Plan says Original Medicare is responsible 
for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on March 16, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services 
provided from March 19, 2022, to March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 12, 2022, billed with 
codes 81240, 81241, 81225, 81226, 81328, 81401 and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
June 12, 2022, billed with codes 81240, 81241, 81225, 81226, 81328, 81401 and 81479.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a transthoracic echocardiogram (TTE) with doppler provided 
on May 17, 2022, by an out-of-network provider. You asked the Plan to pay for the TTE with doppler. You say that the services were medically necessary. The 
Plan denied your request. The Plan says authorization was not obtained prior to services being rendered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care. 
 
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 TTE with doppler. Our reviewer says 
that the records do not indicate that the care provided was medically necessary. Our physician reviewer found 
the enrollee had an ECHO which showed no significant change to prior with diagnosis of cardiomyopathy and 
mechanical mitral valve. It possibly would have been medically reasonable to delay the services until when 
enrollee returned to his/her service area. 
 
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 TTE with doppler have not been met. Therefore, we decided that the Plan 
does not have to pay for a transthoracic echocardiogram (TTE) with doppler provided on May 17, 2022, by an 
out-of-network provider.
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 4, 2020, to December 31, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provider did not send in supporting documentation of their billed PDM 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 that the available medical records do 
not support that the enrollee had shortness of breath while lying flat. The enrollee appeared to improve with 
increased oxygen flow. 
 
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 4, 2020, to 
December 31, 2020.