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

 
We decided that the Plan does not have to pre-approve prostate artery embolization (PAE). 
 
You asked the Plan to pre-approve PAE. You say that you would like reconsideration because the requested 
procedure is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria for coverage. 
 
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 PAE. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PAE is considered an experimental technique to treat symptomatic benign prostatic 
hyperplasia. Very limited studies have demonstrated possible short-term safety and efficacy.  The most recent 
American Urological Association guidelines do not recommend this procedure outside of a clinical trial 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 PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve prostate artery embolization (PAE).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You did not provide an argument with your appeal request. The 
Plan denied your request. The Plan says IRF is not medically necessary, and you can be managed at a lower 
level of care. 
 
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 you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular 
physician evaluation. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a skilled nursing facility (SNF) stay 
provided from August 1, 2021, to August 31, 2021. 
 
You asked the Plan to reduce the copayment for a SNF stay. You say that you are being told you owe the 
provider over $20,000 and the dates and information do not match up with your coverage. You also say you are 
unable to get help with the billing situation from the provider since you are above your out-of-pocket. 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). The enrollees contract with the Plan says that they must pay a $0 copayment for days 1-20 for a skilled nursing facility stay. The Plan contract also says there is a $172 
copayment for days 21-100.  
 
The enrollee is not being charged for the first 20 days they were in the SNF, from July 24, 2021, to August 12, 
2021. According to the Plan, the out-of-pocket maximum was not met until September 1, 2021. Therefore, the 
enrollee has to pay a total of $3,096, which is a $172 copayment for the remaining 18 days from August 13, 
2021, to August 31, 2021 ($172 copayment x 18 days = $3,096). A SNF stay falls within the Skilled Nursing 
Facility (SNF) Care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for a 
skilled nursing facility (SNF) stay provided from August 1, 2021, to August 31, 2021.  
 
Your complaint about not being able to get help from the providers office regarding billing is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 6, 2021. 
 
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 the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97530) provided on October 6, 2021. 
 
You asked the Plan to pay for the therapy services. 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 therapy services provided and billed incident to 
the services of a physician/NPP also must meet all incident-to requirements. 
 
We find that CPT code 97530 is not supported in the record. Specifically, the record shows that this claim was 
billed by a nurse practitioner and the services were rendered by an occupational therapist. A nurse practitioner 
cannot bill for the services of an Occupational Therapist. Therefore, we decided that the Plan does not have to 
pay for the therapy services (97530) provided on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 28, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment cannot be made for this service 
under Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray services coded as 73650 LT and 73650 RT 
provided on September 27, 2021. 
 
You asked the Plan to pay for the X-ray services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate place of service code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that a 
physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a 
minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the 
patient actually receives the face-to-face encounter. 
 
We find that CPT code 73650 LT and 73650 RT is not supported in the medical record. Specifically, these 
services were not billed with the appropriate POS code to indicate where the enrollee was currently receiving 
inpatient care. Based on this information, we decided that Medicare rules for coverage of the X-ray services 
have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services coded as 
73650 LT and 73650 RT provided on September 27, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for fluorescence in situ hybridization (FISH) testing provided on 
November 2, 2021. 
 
You asked the Plan to pay for FISH testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is 
not covered for screening purposes. 
 
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. 
 
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that 
FISH testing would not be covered. Under Medicare rules, this means FISH testing is considered approved by 
the plan. Therefore, we decided that the Plan has to pay for fluorescence in situ hybridization (FISH) testing 
provided on November 2, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on October 18, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test is medically necessary for those who 
have decided to seek further treatment. The Plan denied your request. The Plan says the testing was not 
approved by the ordering provider. 
 The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician 
who is treating the beneficiary. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show that the 
testing was ordered by the enrollees treating physician for a specific medical problem. Based on this 
information shows that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan 
does not have to pay for the FoundationOne testing provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on October 28, 2021. 
 
You asked the Plan to pay for the testing services. You say that the documentation supports the billing. The 
Plan denied your request. The Plan says the documentation does not support 22 or more drug classes. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. The records do not show that 22 
or more drug classes were ordered to be tested based on clinical history and risk assessment. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing services provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Arthroscopy (29877) provided on September 8, 2021. 
 
You asked the Plan to pay for code 29877. 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. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 29877 
is a column II code to column I code 29884. 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 the Arthroscopy (29877) provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobility back brace (L0650), provided on November 13, 
2020. 
 
You asked the Plan to pay for the mobility back brace. You say that the items are medically necessary. The 
Plan denied your request. The Plan says there is insufficient documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The medical records submitted do not indicate the medical necessity of the item ordered and does not discuss the need for one. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the mobility back 
brace (L0650), provided on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on March 24, 2020. 
 
You asked the Plan to pay for the outpatient services. 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. The 
rules say that when an outpatient claim has been submitted with an invalid procedure code, the entire claim will 
be returned to the provider for reprocessing. 
 We looked at the file and Medicare rules. The claim that has been submitted includes an invalid procedure 
code. This means that this claim will be returned to the provider for corrections. Based on this information, we 
decided that Medicare rules for coverage of the outpatient medical services have not been met. Therefore, we 
decided that the Plan does not have to pay for the outpatient services provided on March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the low load dynamic stretching splint (E1805), provided on 
October 12, 2021. 
 
You asked the Plan to pay for the low load dynamic stretching splint. You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is experimental. 
 
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 pay for the low load dynamic stretching splint. Our 
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation indicates that the clinical value and effectiveness of the requested 
splint in the setting of contractures of the fingers secondary to frostbite has not been demonstrated in the 
literature. 
 
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 low load dynamic stretching splint have not been met. Therefore, we 
decided that the Plan does not have to pay for the low load dynamic stretching splint (E1805), provided on 
October 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83540, 83550 and 
83970) provided on August 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is no contractual agreement in place indicating that the CPT codes at issue are included in the dialysis 
rate. The Plan denied your request. The Plan says the dialysis center is responsible for laboratory services 
related to ESRD. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services (82310, 82728, 83540, 83550 and 83970) provided on August 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve 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 does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee is ambulating more than 100 feet. Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition. The enrollees 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on March 31, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the documentation submitted is insufficient. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery. There is no physician order, and the 
date of service does not match the date of delivery or shipping. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (81225, 81226, 81230, 81240, 81241, 
81291, 81335, 81408, and 81479) provided on May 25, 2021 
 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 the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT 
codes describing the component test results. 
 
We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (81225, 81226, 81230, 81240, 81241, 81291, 81335, 81408, and 81479) 
provided on May 25, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the addition of a tooth to existing partial denture (D5650), 
and addition of clasp to a partial denture (D5660 x 2) provided on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told if you stayed in network, the plan 
would cover 50% of your dental needs. The Plan denied your request. The Plan says 1 denture adjustment is 
covered every calendar year. The Plan also says that the frequency limit has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and 1 denture adjustment is covered 
every calendar year, the frequency limit has been exceeded. The record shows that the Plan paid for a denture 
adjustment that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to existing partial denture (D5650), and addition of clasp to a partial denture (D5660 x 2) provided on December 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard. 
 
You asked the Plan to pre-approve Gammagard. You say that this drug is medically reasonable and necessary. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 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 Gammagard.  
 
Benefits for Gammagard 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 pay for the home blood glucose monitor (E0607) provided on July 9, 
2021. 
 
You asked the Plan to pay for the home blood glucose monitor. 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. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the home blood glucose monitor (E0607) provided on July 9, 
2021.