Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine for shingles (90750) provided on October 29, 2021.

You asked the Plan to pay for the vaccine for shingles. You say that this was a medically necessary procedure and should be covered. The Plan denied your request. The Plan says coverage is not available for this vaccine under your medical benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine for shingles. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the vaccine for shingles. Therefore, we decided that the Plan does not have to pay for the vaccine for shingles (90750) provided on October 29, 2021.

Benefits for the vaccine for shingles 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammography (77065) 
provided on September 2, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic mammography. You say that the services should 
be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
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 an $80 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 You have been asked to pay an $80 copayment for a diagnostic mammography. Diagnostic mammograms 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 copayment for a diagnostic mammography (77065) provided on September 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from March 
12, 2020, to March 30, 2020. 
 
You asked the Plan to pay for the inpatient psychiatric services. You say that the enrollees plan is responsible 
for payment. The Plan denied your request. The Plan says there were no medical records provided to support 
that the services were medically necessary. 
 
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 inpatient psychiatric hospitalization 
provided from March 12, 2020, to March 30, 2020 have not been met. Specifically, the file shows that the Plan 
made 3 attempts to obtain medical records from the provider and nothing was received. Therefore, we decided 
that the Plan does not have to pay for the inpatient psychiatric hospitalization provided from March 12, 2020, 
to March 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.

You asked the Plan to pre-approve home health services. You say that you are not receiving the level of care you need and do not have family to help. You say that you need more resources and want the authorization extended to get your strength back up. The Plan denied your request. The Plan says your request is not medically necessary because your records do not show that you are under the care of a physician or other allowed practitioner who has developed and certified a plan of care, ordering additional services for you.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our reviewer says that the provided records do not document any acute or unstable medical conditions or changes in medication or treatment which would necessitate any further skilled nursing or therapy visits beyond what has already been approved. Our physician reviewer found that there are no medical notes from your treating physician documenting an order or need for additional skilled nursing or therapy services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.

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 were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you should be able to go to rehabilitation to 
get stronger. The Plan denied your request. The Plan says you have no skilled nursing needs. 
 
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 the SNF services. Our reviewer says 
that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily 
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional 
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not 
require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, 
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of 
the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled 
nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and knee injection to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit and knee injection. You say that you have been going to this doctor since 2019 and do not want to see another doctor. The Plan denied your request. The Plan says the provider the enrollee is requesting to see is an out-of-network provider. There is a list of in-network providers that provide the same service.

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 an office visit and knee injection to be provided by an out-of-network (OON) provider.
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 an amputation and requires rehabilitation services. He is not self-sufficient to go home by himself. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.

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 it is not clear that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The services can 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulation trial (63650, 63658). 
 
You asked the Plan to pre-approve a spinal cord stimulation trial. You say that the enrollee more than meets the 
requirements for coverage. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation, and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
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 spinal cord stimulation trial. Our 
reviewer says that the requirements for coverage have not been met. Our physician reviewer found the enrollee 
has not had a recent psychological evaluation and clearance.  At this time, the psychological evaluation must be 
repeated as the records show that the evaluation was performed in 2017. 
 
 
 
 
 
 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 spinal cord stimulation trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulation trial (63650, 63658).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 1, 2021. 
 
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 procedure codes 81295 and 81298 are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 81295, 81298, and 81432. Codes 81295 and 81298 are 
column II codes with a modifier indicator of 1 when billed with column I code 81432. The column II codes 
were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on August 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 3, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on September 7, 2021.

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 must follow Medicare rules. The rules say that the Cxbladder testing is non-covered.

We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that The enrollee is stable and ready for 
transfer to LTACH. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria 
for coverage. 
 
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 the enrollee does not require services at the LTACH that are not already available at 
the acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (81219, 81338). 
 
You asked the Plan to pre-approve the genetic testing. You say that the testing is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for laboratories performing single gene technologies, 
a sequential genetic testing approach is expected. Once a positive result is obtained and the appropriate 
diagnosis is established, further testing should stop. 
 
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 genetic testing. Our reviewer says 
that the requested testing is medically necessary. Our physician reviewer found per the National 
Comprehensive Cancer Network Guidelines Version 1.2022 Myeloproliferative Neoplasms, molecular testing 
(blood or bone marrow) for JAK2 V617F mutation; if results are negative, it is appropriate to test for CALR 
and MPL mutations for patients with essential thrombocythemia. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve genetic testing (81219, 81338).  
 
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: 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 the LTACH services. You say that transfer to an LTACH is medically 
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an 
LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH 
would provide no additional services. With more time in the current setting, clinical stability can be ensured 
such that the appropriate lower level of care can be determined. 
 
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 the enrollee still appears to be unstable, requiring additional short-term acute care 
services for weaning that can safely be administered at the current facility. The enrollee does not require 
services at the LTACH that are not already available and covered at the current facility. Transfer to LTACH is 
not medically necessary as it would not be clinically advantageous. Transfer may be considered when the 
enrollee is more stable and when treatment has completed.  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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 2021. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission.
You asked the Plan to pre-approve acute inpatient hospital admission. You say that the admission is medically
necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital admission. Our
reviewer says that the documentation does not support that the criteria for an inpatient admission is medically
necessary. Our physician reviewer found the requested inpatient services are for a planned (non-emergent)
ORIF procedure.
The reviewer found that based on the stable and controlled medical conditions and low-risk procedure, there
was no expectation, based on the provided notes, that you would require hospital services that would likely
cross 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital admission have not been met. Therefore, we decided
that the Plan does not have to pre-approve an acute inpatient hospital admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
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 you appear to be somewhat stable and improving and should require only short-term 
additional acute care services that can safely be administered at the current facility. You do not require services 
at the LTACH that are not already available and covered at the current facility. There are no services at the 
LTACH that the patient requires that are not already available and covered at the current facility. Transfer to 
LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care 
may be considered when treatment has completed. 
 
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 LTACH services.