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

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 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 genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
 
 
 We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology rendered on July 27, 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 PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. 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 pay for the surgical pathology 
rendered on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. 
The record indicates that the enrollee has severe spinal stenosis at L3-L4, the level requested for treatment. The 
elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 14, 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 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 these 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 the laboratory services rendered on May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right reverse total shoulder arthroplasty. 
 
You asked the Plan to pre-approve a right reverse total shoulder arthroplasty. You say that the enrollee has 
degenerative chases of the glenohumeral joint. You say that, due to the enrollee's degeneration of her rotator 
cuff, you do not believe that she will benefit from an arthroscopic rotator cuff as her degenerative changes are 
that significant. The Plan denied your request. The Plan says there is no documentation of degenerative joint 
disease and non-repairability of the rotator cuff. The Plan says that the requested surgery is therefore not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 a right reverse total shoulder 
arthroplasty. Our reviewer says that a right reverse total shoulder arthroplasty is not considered medically 
reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident 
regarding imaging evidence of a symptomatic large and massive rotator cuff tears without cuff-tear 
arthropathy. Additionally, detailed documentation is not evident regarding trial and failure of recent, 
reasonable, and comprehensive less invasive conservative care measures.  There is no documentation of any physical therapy or injections having been trialed and failed. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. 
 
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 right reverse total shoulder arthroplasty have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a right reverse total shoulder arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 30, 2020, to 
September 4, 2020, as billed with Diagnosis Related Group (DRG) 872. 
 
You asked the Plan to pay for inpatient services billed with DRG 872. You say that these services were 
medically necessary, and this claim is supported in the record. The Plan denied your request. The Plan says DRG 872 is not supported as the primary diagnosis of sepsis due to pseudomonas (A41.52) is 
not supported in the medical record. The Plan argues that DRG 690 is more appropriate in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. DRG 872 requires a diagnosis of sepsis due to pseudomonas 
(A41.52). 
 
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 inpatient services billed with DRG 872. Our 
reviewer says that the diagnosis of sepsis due to pseudomonas (A41.52) is not supported in the medical record 
for the hospital care in question. Our physician reviewer found that the documentation is unclear regarding a 
diagnosis of sepsis. Even though sepsis is documented throughout the medical record, supporting 
documentation was not found. The appeal letter mentions the enrollee met sepsis with fever, tachycardia, and 
tachypnea. SIRS criteria are expected as an appropriate response to infection, values trended down with 
intravenous (IV) fluids and IV antibiotics. While the enrollees presenting bilirubin of 1.2 is noted, this value 
was not reassessed following IV fluid hydration. The enrollees elevated lactic acid of 3.7 at 0705 was re-
evaluated and trended down to WNL following IV hydration. Repeat lactic acid at 0947 was 0.7. There was no 
evidence of blood gases done to support a P/F ratio calculation. There is no documentation of persistent 
hypotension or hemodynamic instability. The review has determined that the medical records do not support 
the billing of primary diagnosis sepsis due to pseudomonas (A41.52). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient services billed with DRG 872 have not been met. Therefore, we 
decided that the Plan does not have to pay for the inpatient hospital care provided from August 30, 2020, to 
September 4, 2020, as billed with Diagnosis Related Group (DRG) 872.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing services. 
 
You asked the Plan to pre-approve the skilled nursing services. The Plan denied your request. The Plan says the 
Skilled Nursing Facility (SNF) services you are requesting do not meet the requirements for approval. 
 
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 skilled nursing 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. 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 pre-approve skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office or other outpatient visit and supplies and equipment 
to safely treat patients during the PHE, provided on April 19, 2021. 
 
You asked the Plan to pay for an office or other outpatient visit and supplies and equipment to safely treat 
patients during the PHE. The Plan denied your request. The Plan says these services are excluded from 
coverage when ordered or performed by a Doctor of Chiropractic. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 We looked at the file and Medicare rules. The only chiropractic service Medicare covers is manual 
manipulation of the spine to correct a subluxation. Therefore, we decided that the Plan does not have to pay for 
an office or other outpatient visit and supplies and equipment to safely treat patients during the PHE, provided 
on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve the seat lift mechanism. You say that the chair lift is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
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 seat lift mechanism. Our reviewer 
says that the seat lift mechanism is not medically necessary. Our physician reviewer found the records do not 
show that the patient is completely incapable of standing from a chair in the home. The records show that the 
patient has the ability to ambulate. 
 
 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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 28, 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 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 these 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 the laboratory services rendered on July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tooth re-implantation and/or stabilization of accidentally 
evulsed or displaced tooth (D7270 x 2) and the after hours office visit (D9440) provided on October 31, 2021. 
 
You asked the Plan to pay for the dental services. You say that you fell and knocked out your 2 front teeth. You 
say that 2 others broke. You say that the hospital was not equipped to handle what needed to be done. You say 
that you met your dentist at their office which allowed you to have your teeth saved. You also say that these 
should be covered. The Plan denied your request. The Plan says the services you received are not listed as 
covered. 
 
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 dental services you received are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the tooth 
re-implantation and/or stabilization of accidentally evulsed or displaced tooth (D7270 x 2) and the after hours 
office visit (D9440) provided on October 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 13, 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 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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Actemra Actpen. 
 
You asked the Plan to pre-approve the Actemra Actpen. You say that you feel this drug should be covered. The 
Plan denied your request. The Plan says Actemra Actpen for subcutaneous injection once weekly is self-
administered. 
 
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 Actemra Actpen.  
 
 
 Benefits for the Actemra Actpen 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluid washings, hybridization and sex chromatin 
identification procedures (88108) provided on September 23, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician performed medical 
services and sent the specimens to your laboratory for examination. 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 fluid washings, hybridization and sex chromatin 
identification procedures (88108) provided on September 23, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on October 27, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON telehealth visit. You say that you believe the provider of service is a 
network provider. The Plan denied your request. The Plan says telehealth services are only covered in-network. 
The provider of service is not a network provider with this member's specific plan. 
 
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 telehealth visit provided on October 27, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 15, 2019, and  
August 22, 2019. 
 
You asked the Plan to pay for the physician's services. You say that the claims were filed timely. The Plan 
denied your request. The Plan says the claim was filed past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the physician's services was not filed until April 22, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on July 15, 2019, and  
August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy procedure (code 97110), the manual therapy 
techniques (97140), and the established patient office visit (code 99213) you received from a chiropractor on 
July 29, 2021. 
 
You asked the Plan to pay for the therapy procedure, the manual therapy, and the office visit.. You say that the 
Plan should pay for this with no out-of-pocket expenses other than your copayment. The Plan denied your 
request. The Plan says the only chiropractic services covered are services for manual manipulation of the spine.  
These additional services you received are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 The records show that the service at issue are not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapy procedure (code 97110), the manual therapy techniques (97140), 
and the established patient office visit (code 99213) you received from a chiropractor on July 29, 2021.