Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home prothrombin time/international normalized ratio 
(PT/INR) testing materials to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve PT/INR test supplies. You say that the enrollee is in need of this device but 
the recommended companies do not offer it. The Plan denied your request. The Plan says the denial of 
authorization for these items is correct, because this provider is out-of-network with the Plan and these supplies 
can be obtained from an in-network supplier. 
 
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 
home prothrombin time/international normalized ratio (PT/INR) testing materials to be provided by an out-of-
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life2000 System. 
 
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 services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Life2000 System is not a 
true ventilator because it is not capable of providing full ventilatory support. It is intended for use during 
activity, but there is no convincing medical evidence that this device is beneficial in the treatment of lung 
disease. The enrollee does not meet the Medicare criteria for a home ventilator or ventilatory support. There is 
no documentation of the diagnosis of chronic obstructive pulmonary disease (COPD) with results of pulmonary 
function testing. She does not have thoracic restrictive disease (chest wall or spinal deformity causing restriction) or neuromuscular disease. The services are therefore 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 a Life2000 System.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on 
January 27, 2022.  
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a 
covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The targeted genomic sequence analysis panel at issue in this appeal was requested solely for screening 
purposes. The documentation does not support that this testing was likely to impact therapeutic decision-
making in the clinical management of the enrollee. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis 
panel provided on January 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service February 18, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on February 16, 2022, by an out-of-
network provider. 
 
You asked the Plan to pay for the office visit. You say that authorization is not required for this service. The 
Plan denied your request. The Plan says the provider is not a network provider and services are not urgent or 
emergent, nor were they approved in advance.      
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on February 16, 2022, by 
an out-of-network provider.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the at-home coronavirus test kits purchased on January 17, 2022. 
 
You asked the Plan to pay for the at-home coronavirus test kits. You say that you were directed by a plan 
representative to pay out of pocket for the tests and submit for reimbursement. The Plan denied your request. 
The Plan says that the test kits were not eligible for reimbursement at the time of purchase. 
 
The Plan must follow Medicare rules. Medicare rules say that plans and insurers are required to cover at-home 
over-the-counter COVID-19 tests purchased on or after January 15, 2022. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the at-home coronavirus test kits have been met. Specifically, the test kits were purchased after 
January 15, 2022. Therefore, we decided that the Plan has to pay for the at-home coronavirus test kits 
purchased on January 17, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay the claim for the inpatient care provided from November 11, 2021, to 
November 19, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that this claim was billed appropriately and is 
supported in the medical record. The Plan denied your request. The Plan says that this claim is billing nine (9) 
days of inpatient care, but based on the date range, only eight (8) days are billable, as the day of discharge does 
not count for cost per Medicare rules. 
 
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, it is unclear where the Plan found information to support that nine 
days of inpatient care are being billed on this claim. The room/board revenue codes do not exceed eight units in 
total, and the AMT quantity listed on the claim is eight. We do agree with the Plan that eight days of service 
are reflected by the date range in question; however, we do not see where nine days are requested. This means 
that the Plans denial is not substantiated in this case. Therefore, we decided that the Plan has to pay the claim 
for the inpatient care provided from November 11, 2021, to November 19, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services of a registered nurse (RN) 
(G0299), skilled nursing services of a licensed practical nurse (LPN) (G0300), and nursing care in the home 
(S9123). 
 
You asked the Plan to pre-approve skilled nursing services of a RN and LPN, and nursing care in the home. 
You say that the enrollee only trusts medical professionals and nurses to administer insulin. You also say that 
the enrollee's family is not trained to administer the enrollee's insulin. The Plan denied your request. The Plan 
says the enrollee does not meet the medical necessity criteria for coverage.  
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 skilled nursing services of a RN and 
LPN, and nursing care in the home. Our reviewer says that the requested home health nursing services are not 
medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs. It is not clear that the enrollee is homebound. Our reviewer also found that there is no 
evidence of an acute illness or injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing services of a RN and LPN, and nursing care in the home have 
not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services of a 
registered nurse (RN) (G0299), skilled nursing services of a licensed practical nurse (LPN) (G0300), and 
nursing care in the home (S9123).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) psychotherapy 
services provided on October 8, 2021. 
 
You asked the Plan to waive the copayment for the OON psychotherapy services. You say that you were 
informed that the provider was in-network. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 
copayment for each therapy visit with an out-of-network provider.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $55 copayment for the OON psychotherapy services. The OON psychotherapy services fall within the 
Outpatient Mental Health 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 
out-of-network (OON) psychotherapy services provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on February 16, 
2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the enrollee was referred to this provider by the 
medical center to see if it was going to be necessary to have a mastectomy before going through with the 
surgery. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99205) provided on 
February 16, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88304, 88311, 88312) provided on November 
9, 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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 (88304, 88311, 88312) provided on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that Medicare doesn't pay for LTACH care that appears to be a 
permanent hospital placement. 
 
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. The enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on November 19, 
2021. 
 
You asked the Plan to waive the copayment for an injection. You say that you had a prior authorization and 
would like for the service to be covered. The Plan denied your request. The Plan says the proper coinsurance 
was applied for the service that was rendered. 
 
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 a 20% 
coinsurance for each In-network Medicare-covered Part B drug. The total amount allowed for the injection was 
$1,271.40 with a coinsurance of $254.28 ($1,271.40 total amount allowed x 20% coinsurance). 
 
  You have been asked to pay a $254.28 coinsurance for an injection. An injection falls within the Outpatient 
Hospital Services 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 an injection provided 
on November 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215) and prolonged office visit (G2212) 
provided on May 2, 2021. 
 
You asked the Plan to pay for the physician service. You say that the enrollee was no longer enrolled in hospice 
on the date of service in this case. 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. 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 May 1, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the office visit (99215) and 
prolonged office visit (G2212) provided on May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
November 3, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you would like the bill to 
be paid in full. The Plan denied your request. The Plan says the proper copayment was applied for the service 
that was rendered. 
 
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 a $40 
copayment for Lab Services at an Outpatient Hospital.  
 
  You have been asked to pay a $40 copayment for the laboratory services. The laboratory services falls 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 the laboratory services provided on November 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology genetic testing coded 81518 provided on 
September 30, 2021. 
 
You asked the Plan to pay for the oncology genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81518 is not supported in the medical record. Specifically, the documentation does not 
support how the enrollee came to you, the serving provider. No medical records were provided for the services 
rendered. The Plan attempted to obtain this information three times without response. Based on this 
information, we decided that Medicare rules for coverage of the oncology genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the oncology genetic testing coded 81518 
provided on September 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2022, 
to February 8, 2022. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
did not require skilled services on a daily basis. The Plan also says that ongoing skilled care could have been 
provided in an alternative setting on an intermittent basis. 
 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 18, 2022, to February 8, 2022.