Persius/hicric huggingface dataset:
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 enrollee requires prolonged and 
intensive skilled services that are not available at a skilled level of care. The Plan denied your request. The Plan 
says the enrollee is receiving appropriate inpatient care and is currently unstable for transfer to an LTACH. 
 
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 was admitted with acute on chronic respiratory failure in the setting of 
sepsis from pyelonephritis. The record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services before transitioning to a lower level of care.  The medical record does not indicate that the enrollee requires services that they are not currently receiving but 
that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the disposable drug delivery system, flow rate of 50 ml or 
greater per hour (A4305) provided July 26, 2021 to August 1, 2021 
 
You asked the Plan to pay for the disposable drug delivery system,. You say that the medical records provided 
support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the disposable drug delivery system, have not been met. Therefore, we decided that the Plan does 
not have to pay for the disposable drug delivery system, flow rate of 50 ml or greater per hour (A4305) 
provided July 26, 2021 to August 1, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious disease pathogen identification testing provided on 
April 26, 2022. 
 
You asked the Plan to pay for infectious disease pathogen identification testing. You say that this test is not 
experimental and was medically necessary. The Plan denied your request. The Plan says this panel was not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infectious disease pathogen identification testing have not been met. Specifically, the records show 
that a single panel was ordered and performed, but this service was billed by reporting individual components. Therefore, we decided that the Plan does not have to pay for infectious disease pathogen identification testing 
provided on April 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on June 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 June 22, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for monoclonal antibodies (code M0243) provided on July 19, 2021. 
 
You asked the Plan to pay for monoclonal antibodies. The Plan denied your request. The Plan says that per the 
Plan and Medicare guidelines, COVID-19 treatment of monoclonal antibodies were covered by CMS for 
calendar years 2020 and 2021. 
 
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 not provided us with the rule to support their denial. 
Therefore, we decided that the Plan has to pay for monoclonal antibodies (code M0243) provided on 
July 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that the enrollee needs this medication to better manage 
his condition. 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 Jardiance.  
 
 Benefits for Jardiance 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, foot plates, and power seat 
elevator (E2313, E2377, E2311, E2300, K0108) for an approved power wheelchair. 
 You asked the Plan to pre-approve the wheelchair features. You say that these features are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that seat elevators are non-covered. Standard footplates 
are included with a base wheelchair and cannot be billed separately. Expandable controllers are covered when 
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 wheelchair features. Our reviewer 
says that the requested features are not medically necessary. Our physician reviewer found the wheelchair 
power seat elevator function is non-covered under Medicare rules. The standard footplates are already included 
in the base wheelchair code and the correct code was not used for adjustable footplates. The records show that 
the enrollee is able to operate the power features with their own switch. The expandable controller is not 
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 the wheelchair features have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller, foot plates, and power seat elevator (E2313, E2377, 
E2311, E2300, K0108) for an approved power wheelchair.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on February 7, 2022. 
 
You asked the Plan to pay for pathology services. The Plan denied your request. The Plan says the member was 
in hospice on this date of service. 
 
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 pathology services provided on February 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450-26 billed for date of service December 
15, 2021. 
 You asked the Plan to pay for procedure code 70450-26. You say that you do not believe this code should be 
bundled. The Plan denied your request. The Plan says payment for code 70450-26 is bundled into payment for 
code 70496-26. 
 
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 
70450-26 is a column II code to column I code 70496-26. 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 70450-26 billed for date of service 
December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DPYD (dihydropyrimidine dehydrogenase) (81232) provided 
April 20, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that this letter documents the medical necessity 
of the test requested for the enrollee to inform treatment selection for their cancer. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
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, the CPT Code Manual definition of code 81232 is DPYD (dihydropyrimidine dehydrogenase) (eg, 
5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) 
 
We find that CPT code 81232 is not supported in the medical record. Specifically, the claim was billed with a 
date of service inconsistent with Medicare rules governing laboratory services. The specimen was collected on 
April 1, 2022, rather than the billed date of service April 20, 2022. Based on this information, we decided that 
Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for DPYD (dihydropyrimidine dehydrogenase) (81232) provided April 20, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on May 16, 2022, to May 31, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for home health services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined 
these services can be received in-network. 
 
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 home health services provided on May 16, 2022, 
to May 31, 2022, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from March 23, 2022, to 
May 26, 2022. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says this provider is not 
part of the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Licensed Professional Counselor is not eligible 
to participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Licensed Professional 
Counselor. Medicare says that a Licensed Professional Counselor is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from 
March 23, 2022, to May 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service March 16, 
2022. 
 
You asked the Plan to pay for procedure code 76140. The Plan denied your request. The Plan says the billed 
code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022 billed with 
codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U, 81407, and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the testing 
was billed incorrectly. 
 
 
 
 
 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 
March 2, 2022 billed with codes 81227, 81230, 81231, 81232, 81291, 81306, 81328, 81355, 81335, 0031U, 
0032U, 0033U, 81407, and 81238.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 18, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says traditional 
Medicare pays for hospice services. 
 
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 physician's services provided on January 18, 2022.
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 this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this is not medically necessary, and continued acute 
hospital care was offered, until the enrollee could discharge to a lower level of care. 
 
 
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 medical records do not indicate that the enrollee requires services that she is not 
currently receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you feel you can benefit from additional therapy. 
The Plan denied your request. The Plan says your records do not show that you can participate in skilled 
services on a daily 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that daily skilled services are not required. Our reviewer found that although you are 
limited functionally, the provided records do not document that you have the endurance to participate with 
therapy on a daily basis. Part-time therapy in the long-term care setting is most appropriate at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) provided January 
14, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that you believe these services were 
medically necessary. The Plan denied your request. The Plan says pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0675) provided January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the total electric hospital bed, with any type side rails, with 
mattress (E0265) purchased April 8, 2022. 
 
You asked the Plan to pay for the total electric hospital bed. You say that you feel that this should be covered. 
You paid with your credit card, and it is up to the Plan to prove that you did not pay for it, rather than for you to prove that you did pay for it. The Plan denied your request. The Plan says a total electric hospital bed is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for the total electric hospital 
bed, with any type side rails, with mattress (E0265) purchased April 8, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on March 31, 2022. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says either hospice or Original Medicare is responsible for this 
bill. 
 
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 medical services provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88341, 88342, and 88360) provided 
on January 13, 2022. 
 
You asked the Plan to pay for codes 88341, 88342, and 88360. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 We find that codes 88341, 88342, and 88360 are not supported in the medical record. Specifically, the records 
indicate that the member was an outpatient on the billed date of service. Payment for codes 88341, 88342, and 
88360 are included in the payment to the facility and is the responsibility of the facility to any vendor. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (88341, 88342, and 88360) 
provided on January 13, 2022.