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

 
We decided that the Plan does not have to pre-approve a molecular pathology procedure (81479). 
 
You asked the Plan to pre-approve a molecular pathology procedure. You say that the service is necessary. The 
Plan denied your request. The Plan says the requested service is an excluded benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that since clinical symptoms and diagnosis usually 
occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDX team has determined 
CHD7 gene testing is a statutorily excluded service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a molecular pathology procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a molecular pathology procedure (81479).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services. 
 
You asked the Plan to pre-approve physical therapy services. 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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found as stated in the Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services - L33631: "A therapy plan of care is developed either by the 
physician/NPP [non-physician practitioner], or by the physical therapist who will provide the physical therapy 
services, or the occupational therapist who will provide the occupational therapy services, (only a physician 
may develop the plan of care in a CORF). The plan must be certified by a physician/NPP." A plan of care 
certified by a physician/NPP has not been provided in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CGx Hereditary Cancer genetic testing screening panel 
billed for date of service June 6, 2022. 
 
You asked the Plan to pay for a genetic testing screening panel. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that screening services such as pre-symptomatic 
genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a benefit and 
are not covered. Based on this information, we decided that Medicare rules for coverage of a genetic testing 
screening panel have not been met. Therefore, we decided that the Plan does not have to pay for a CGx 
Hereditary Cancer genetic testing screening panel billed for date of service June 6, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (83521) provided on February 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the 
laboratory services (83521) provided on February 2, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient rehabilitation services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the requested services. You say that you are familiar with the requested 
provider. The Plan denied your request. The Plan says care is available with a network therapist. 
 
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 contract providers 
located within reasonable distance and travel time from your home who can provide the services at issue. We 
found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that 
the Plan does not have to pre-approve outpatient rehabilitation services to be provided by an out-of-network 
(OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 18, 
2022. 
 
You asked the Plan to pay for procedure code 76705. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76705 is bundled into payment for code 93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service July 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion services provided from September 10, 
2021, to October 28, 2021. 
 
You asked the Plan to pay for the home infusion services. You say that the services should be covered. The 
Plan denied your request. The Plan says the claims processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that for services paid on a fee schedule, Medicare 
secondary payment amounts are determined by a formula.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home infusion services have not been met. Specifically, the record shows that the primary plan 
paid more than the Medicare allowed amount, thus no additional payment is required. Therefore, we decided 
that the Plan does not have to pay for the home infusion services provided from September 10, 2021, to 
October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high-strength wheelchair, elevating wheelchair leg 
rests and wheelchair anti-tipping device. 
 
You asked the Plan to pre-approve a high-strength wheelchair, elevating wheelchair leg rests and wheelchair 
anti-tipping device. You say that the items are necessary. The Plan denied your request. The Plan says a high-
strength wheelchair, elevating wheelchair leg rests and wheelchair anti-tipping device 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a high-strength wheelchair, elevating wheelchair leg rests and wheelchair anti-tipping device have not been met. Therefore, we decided that the Plan does not have to pre-approve a high-strength wheelchair, 
elevating wheelchair leg rests and wheelchair anti-tipping device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 74183 and 76376 provided on 
July 19, 2022. 
 
You asked the Plan to pay for the medical services coded 74183 and 76376. You say that you would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on July 30, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for the medical services coded 74183 and 76376 have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded 74183 
and 76376 provided on July 19, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care. 
 
You asked the Plan to pay for 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. 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 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 you do not qualify for SNF coverage. You do not have documented skilled 
nursing or skilled therapy. Daily skilled services are not shown to be required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs can, as a practical matter, 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management (99490, 99439) provided on 
May 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that chronic care management services do not 
require a prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. 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 chronic care management (99490, 99439) provided on May 
16, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided February 25, 2022, to 
February 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the medical criteria for an inpatient admission have 
not been met. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span 
two 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 care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided February 25, 2022, to February 27, 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 for inpatient hospital services provided from July 9, 2021, to July 16, 2021, 
at the DRG originally billed. 
 
You asked the Plan to pay for inpatient hospital services at the DRG originally billed. You say that the services 
at issue have been billed correctly. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
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 case record states that medical records were available for 
review by the Plan; however, no medical records have been forwarded for review by the IRE. We are unable to 
verify the Plans assertion that the services at issue have been billed with the incorrect DRG and principal 
diagnosis code. It is the Plan's responsibility to substantiate its denial with evidence. In this case, the Plan's 
denial has not been substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay 
for inpatient hospital services provided from July 9, 2021, to July 16, 2021, at the Diagnosis Related Group 
(DRG) originally billed.  
 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollees condition they do not meet all the requirements. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for an infection of a prosthetic hip joint.  Medical problems are stable.  There are no complex nursing or rehabilitation needs. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided a 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology testing (0037U) provided on August 
1, 2022. 
 
You asked the Plan to pay for the molecular pathology testing. You say that you would like the Plan to 
reconsider their denial of payment. 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 the molecular 
pathology testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
molecular pathology testing (0037U) provided on August 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder Detect testing (0012M) provided on May 24, 
2022. 
 
You asked the Plan to pay for procedure code 0012M. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder Detect testing (0012M) provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for an office visit provided outside of the Plan's service area in Maryland 
on June 15, 2022. 
 
You asked the Plan to pay for office visit. You say that you obtained authorization. The Plan denied your 
request. The Plan says that this provider is out-of-network with the Plan and authorization was not obtained. 
 
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. Medicare says that plans must pay for emergency and urgently needed services. The Plan contract 
says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal 
dialysis, and pre-approved care. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The claim form submitted by the provider indicates that this service was 
performed outside of the Plans service area in Maryland. The Plan has not submitted medical records or any 
attempts to obtain medical records related to this visit. Without this information, we cannot determine whether 
the services performed were urgent or emergent in nature. Therefore, the Plan has not shown that its decision to 
deny payment for this visit is correct or justified according to Medicare rules and your contract with the Plan. 
Therefore, we decided that the Plan has to pay for an office visit provided outside of the Plan's service area in 
Maryland on June 15, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs, two or more 
administrations, different medications (D9612), removal of impacted tooth - completely bony (D7240), surgical 
placement of implant body: endosteal implant (D6010), surgical access to an implant body (second stage 
implant surgery) (D6011), bone graft at time of implant placement (D6104), and guided tissue regeneration - 
resorbable barrier, per site (D4266).  
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
therapeutic parenteral drugs, two or more administrations, different medications (D9612), removal of impacted 
tooth - completely bony (D7240), surgical placement of implant body: endosteal implant (D6010), surgical 
access to an implant body (second stage implant surgery) (D6011), bone graft at time of implant placement 
(D6104), and guided tissue regeneration - resorbable barrier, per site (D4266).  The Plan agreed to pre-
approved the deep sedation/general anesthesia  first 15 minutes (D9222), and deep sedation/general anesthesia 
 each subsequent 15 minute increment (D9223).