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

 
We decided that the Plan does not have to pay for lab services provided on May 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 2, 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 the enrollee continues to have significant weakness 
and range of motion deficits. The Plan denied your request. The Plan says the request 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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency 
transport (A0427), and ground mileage (A0425) from the airport to the hospital and back provided on June 29, 
2022.  
You asked the Plan to pay for the ambulance services. You say that payment should be made for these services. 
The Plan denied your request. The Plan says ambulance transport is covered to the nearest appropriate facility 
to obtain necessary diagnostic and therapeutic services as well as the return transport. 
 
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by 
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. 
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as 
defined above. It is noted that the only State in which these criteria are met is New York. 
 
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural 
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the 
ambulance service, advanced life support, emergency transport (A0427), and ground mileage (A0425) from the 
airport to the hospital and back provided on June 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on June 
6, 2022, to June 18, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you think this 
copayment is too much. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $270 
copayment per day for days 1 to 7 for inpatient hospital care. This inpatient hospital stay lasted 12 days, 
resulting in a copayment amount of $1,890 ($270 per day for days 1 to 7). 
 
You have been asked to pay $270 copayment per day for days 1 to 7 for inpatient hospital services. This 
item/service falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital services provided on June 6, 2022, to June 18, 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 the enrollee would benefit from inpatient 
rehabilitation services due to their medical complexity. The Plan denied your request. The Plan says the 
enrollee's needs can be met at a lower level of care such as a skilled nursing facility, outpatient setting or home 
health 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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and 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 enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee's needs can be met at a lower 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
May 20, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an approved test which was provided for a 
covered indication. The Plan denied your request. The Plan says the claim for this molecular pathology testing 
did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. 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 May 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that beneficiaries must have been an inpatient of a 
hospital for a medically necessary stay of at least 3 consecutive calendar days for SNF services to be approved. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF care have not been met. Specifically, the documentation does not show that the enrollee had a 
3-day inpatient hospital stay prior to this request Therefore, we decided that the Plan does not have to pre-
approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you have chronic hypoxia and hypercapnic 
respiratory failure and have been admitted recently for this. The request is for AVAPS, home ventilator and 
without it, you are at risk of hypercapnic failure requiring hospitalization or death. The Plan denied your 
request. The Plan says your request is not medically necessary because your records do not show evidence of 
failure of BiPAP. You are currently on supplemental oxygen with no pressure support. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that you have 
chronic hypoxic and hypercapnic respiratory failure from chronic obstructive pulmonary disease. The record 
indicates that you were successfully treated with BiPAP previously. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. You could be treated with a BiPAP machine with AVAPS capability. The plan has indicated coverage 
for such a device is available upon request. The elements of the coverage criteria are not satisfied. The 
requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (codes 97162 and 97140) billed for date of 
service March 9, 2022. 
 
You asked the Plan to pay for the therapy services. You say that other claims for this provider and member 
have been paid. This claim was denied incorrectly because this provider is a physical therapist. The Plan denied 
your request. The Plan says you did not bill these therapy services with the appropriate required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that when billing for any outpatient rehabilitation 
service, providers must bill with the appropriate modifier (i.e., GN, GO, or GP) to indicate the discipline of the 
plan of care under which the service is delivered.  In this case, you did not bill with any modifier.  You stated 
in your appeal that the services were provided by a physical therapist, so the GP modifier should have been 
appended to these services on the claim.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay 
for therapy services (codes 97162 and 97140) billed for date of service March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and diagnostic radiology services provided on 
February 21, 2022. 
 
You asked the Plan to pay for an office visit and diagnostic radiology services. You say that you are a poor 
senior citizen that is not able to pay for doctors and specialist bills that were granted to you by the insurance 
Plan. The Plan denied your request. The Plan says members may self-refer to a network chiropractor for 12 
visits per calendar year including select x-ray procedures. The members claim history shows he has exhausted 
the 12 visits allowed for chiropractic services. The Plan has paid for 12 visits in 2022 and there is no 
authorization on file for any additional visits. 
 
The Plan contract covers a supplemental chiropractic benefit. The Plan covers additional chiropractor visits for 
12 visits per calendar year for routine spinal adjustments, new and established patient examinations and select  
x-ray procedures. We looked at the file and the Plans rules. The file shows that you have exhausted the supplemental 
chiropractic benefit for 2022. Therefore, we decided that the Plan does not have to pay for an office visit and 
diagnostic radiology services provided on February 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has plaque psoriasis. She 
has not tried and failed the Plan's required drugs, Remicade, Inflectra, or Infliximab and Stelara. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Ilumya is not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Ilumya.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services rendered on April 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 15771 and 15772. The Medicare Fee Schedule Database contains a 
surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is 
not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage 
criteria for these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
assistant surgeon services rendered on April 26, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that effective January 18, 2017, the Centers for 
Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence 
Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug 
Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve a leadless pacemaker (33274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 85060 billed for date of service July 28, 
2022. 
 
You asked the Plan to pay for procedure code(s) 85060. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this code is included in the facility payment and is not separately 
payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 8 for CPT code 85060. This means there 
is both a professional and technical component for the CPT code. In this case, an appropriate modifier to 
indicate the professional component has not been billed with CPT code 85060. Based on this information, we 
decided that Medicare rules for coverage of procedure code 85060 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 85060 billed for date of service July 28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date of service in question. 
 
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 services provided on January 26, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) provided on January 6, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that they do not have to pay for 
this service. 
 
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. Specifically, the Plan has provided no reason for denial. The only possible 
reason provided in the case file is, payment made according to Medicare allowable rate; however, no 
evidence that any amount of reimbursement was provided for this service was included for review. Without a 
clear reason and supporting evidence, the Plans denial is not substantiated. Therefore, we decided that the Plan 
has to pay for laboratory testing (81455) provided on January 6, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute. 
 
You asked the Plan to pre-approve a crutch substitute. You say that you have knee surgery on December 15th 
and the knee scooter is needed. The Plan denied your request. The Plan says the requested item is not covered 
under your contract with them or under Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for crutch 
substitutes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crutch substitute.