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

 
We decided that the Plan does not have to pay for lab services (81161, 81286, 81413, 81414, 81442, 81479) 
provided October 26, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 lab services (81161, 81286, 81413, 
81414, 81442, 81479) provided October 26, 2021. have been met. No clinical records were provided to support that the services were medically necessary. Therefore, we decided that the Plan does not have to pay for lab 
services (81161, 81286, 81413, 81414, 81442, 81479) provided October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on January 
20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you were under the impression that 
this would be covered by the Plan. The Plan denied your request. The Plan says the dental service was received 
from an OON provider and is not covered by your supplemental benefits. 
 
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 record shows you received the requested dental services from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit when 
received from an OON provider. Therefore, we decided that the Plan does not have to pay for the periodontal 
maintenance (D4910) provided on January 20, 2022, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ablation procedure (64625). 
 
You asked the Plan to pre-approve the ablation procedure. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 pre-approve the ablation procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered investigational because of the wide variation in efficacy 
described in the literature. More research is needed. 
 
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 ablation procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an ablation procedure (64625).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 15, 2021. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services provided are not supported by the documentation. 
 
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. 
 
Review of the file shows that no medical records were provided to show the necessity of the services rendered. 
This means there is no documentation in the case file to support that the laboratory testing at issue in this 
appeal was not 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 laboratory services provided on 
November 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 3, 
2021. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like payment to be 
reconsidered for the services performed. The Plan denied your request. The Plan says the enrollee was enrolled 
in hospice on this date of service, and traditional Medicare is the primary payer when in hospice care. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care (99231) provided on October 3, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
October 6, 2021. 
 
You asked the Plan to pay for the hospital discharge day management. You say that you would like payment to 
be reconsidered for the services performed. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on this date of service, and traditional Medicare is the primary payer when in hospice care. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the hospital discharge day management (99238) provided on 
October 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the abdominal 
aorta. 
 
You asked the Plan to pre-approve the CT scan. You say that you need to have a procedure done urgently 
because of the pain in your legs and arms. The Plan denied your request. The Plan says the medical records do 
not indicate a comprehensive physical evaluation of the lower extremities. Therefore, the CT scan is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our reviewer says that the 
CT scan of the abdominal aorta is not medically needed at this time. Our physician reviewer found that the 
enrollee had an ultrasound exam which showed that the bilateral external iliac and lower extremity arteries are 
normal in caliber with no significant plaque or aneurysm. As such, there is no evidence to suggest a need to 
perform a CT angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff. In 
summary, there is insufficient documentation to support the medical necessity for the CT angiography 
abdominal aorta and bilateral iliofemoral lower extremity runoff. 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computerized tomography (CT) scan of the abdominal aorta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 1, 2022 billed with 
codes 81201 and 81317. 
 
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 the services are not payable as billed. 
 
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 
February 1, 2022 billed with codes 81201 and 81317.
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 the enrollee is in the hospital and unable to return 
home in their current condition and they cannot receive the rehabilitation services they need. The Plan denied 
your request. The Plan says the records do not show that the enrollee is able to take part in 3 hours of therapy 5 
days per week due to weakness and fatigue. 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 pay for 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 close supervision 3 times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute nursing needs identified or 
documented. The enrollee does not need 3 hours of therapy 5 days per week of therapies with multidisciplinary 
approach in an IRF. The enrollee is not fitted with a prosthesis yet. 
 
Documentation does not support the medical necessity due to lack of medical complexity and nursing needs for 
admission to an IRF. While the enrollee would benefit from physical therapy and occupational therapy the 
enrollee's rehabilitation needs can be safely 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of extracranial arteries (93880) provided on 
February 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a duplex scan of extracranial arteries. You say that the provider participates with 
the Plan. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized. The services were not authorized, and 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 a duplex scan of extracranial arteries (93880) 
provided on February 9, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
February 15, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 14, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit. The records provided 
for review do not show that the office visit was urgent or emergent. Therefore, we decided that the Plan does 
not have to pay for the office visit provided on June 14, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on October 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization 
is required prior to an out-of-network visit. 
 
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 domiciliary services provided on October 18, 
2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99222) provided on October 2, 2021. 
 
You asked the Plan to pay for the initial hospital care. You say that you would like payment to be reconsidered 
for the services performed. The Plan denied your request. The Plan says the enrollee was enrolled in hospice on 
this date of service, and traditional Medicare is the primary payer when in hospice care. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care (99222) provided on October 2, 2021.
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 the enrollee has little to no caregiver support at 
home. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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's medical status does not require intensive physician and nursing 
oversight in an IRF. While the enrollee may benefit from additional multiple therapies, including physical and 
occupational therapy, the documentation does not reveal that the enrollee's functional status requires this therapy on an intensive IRF level. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis. 
 
You asked the Plan to pre-approve Restasis. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
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 Restasis.  
 
 
 Benefits for Restasis 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) therapy.  
You asked the Plan to pre-approve TMS therapy. You say that this is needed. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for TMS. 
 
The Plan follows Medicare rules. Medicare rules state that TMS is only covered if certain criteria are met. 
 
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 TMS therapy. Our reviewer says that 
the enrollee does not meet the Medicare criteria for TMS therapy. Our physician reviewer found the enrollee 
has undergone psychotherapy which was not documented as being effective. There is not documentation of 
electroconvulsive treatment or TMS in the past. The enrollee does not have an indication for which the 
requested TMS may be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TMS therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically 
necessary. The Plan denied your request. The Plan says the enrollee has not finished their full course of care in 
the hospital. The enrollee is not medically stable to transfer to another level of care. The enrollee's needs may 
be met in the current hospital setting. 
 
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 appears to be somewhat unstable and requires additional acute care 
services that can safely be administered at the current facility until more appropriate for a lower level of care. 
The enrollee does not require services at the LTACH that are not already available at the current facility. 
 
  There are no services at the LTACH that the enrollee requires that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer 
and as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
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 the LTACH services.