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

 
We decided that the Plan does not have to pre-approve the polysomnography (CPT code 95811) to be provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the service is medically necessary. 
The Plan denied your request. The Plan says there is an in-network provider that can perform the services the 
enrollee needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the polysomnography (CPT code 95811) to be provided by an out-of-network provider.
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 are requesting SNF services for the enrollee due 
to a fall. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 daily skilled services are not necessary. Our physician reviewer found that the 
medical records do not document that you require services on an inpatient basis, only in a skilled nursing 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81599) provided May 2, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a diagnostic laboratory test using Next 
Generation Sequencing must have an FDA approved or cleared indication for use in that patients cancer. 
 
We looked at the file and Medicare rules. The PrismRA test at issue is not FDA approved. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (81599) provided May 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 64490 and 64491 billed for date of service 
February 15, 2022.  
You asked the Plan to pay for procedure codes 64490 and 64491. You say that payment is required for all 
covered services. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64490 and 64491 is 1. The MAI value for this code is 2. You billed 2 units 
of each code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure codes have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 64490 and 64491 billed for date of service February 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 17, 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 September 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on August 8, 
2021. 
 
You asked the Plan to reduce the copayment for the urgent care visit. You say that you are being billed for $35 
but already paid your $15 copayment. The Plan denied your request. The Plan says the copayment for urgently 
needed services applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for each visit. Covered services include urgently needed services obtained at a retail walk-in clinic 
or an urgent care center.  
  You have been asked to pay a $35 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the urgent 
care visit provided on August 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service February 8, 
2022. 
 
You asked the Plan to pay for procedure code 99053. You say that you have provided records to support the 
service billed. The Plan denied your request. The Plan says procedure code 99053 is considered bundled and 
not separately payable. 
 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service February 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ongentys. 
 
You asked the Plan to pre-approve Ongentys. You say that this medication is a continuation of therapy and the 
records provided support its need. The Plan denied your request. The Plan says the requested medication does 
not fall under Part B Coverage. The Plan says that the enrollee does not have pharmacy benefits administered 
under this contract. 
 
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 Ongentys.  
 Benefits for Ongentys 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 64483 billed for date of service February 14, 
2022. 
 You asked the Plan to pay for procedure code 64483. You say that providers are not allowed to use modifier 50 
in this case. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 64483 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code 64483 billed for date of 
service February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) 
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including 
needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging 
guidance (ie, fluoroscopy or CT) (CPT code 62323). 
 
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been 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 injection. Our physician reviewer 
found there is no role for a series of three (3) injections. Each injection needs to be evaluated for efficacy and 
duration of pain relief. There is now a 3-month standard after each injection which was not achieved here. 
Therefore, the request is considered not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, 
opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, 
interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or 
CT) (CPT code 62323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022, billed with 
codes 81298, 81292, 81295, & 81317. 
 
You asked the Plan to pay for the genetic testing billed. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
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 
April 28, 2022, billed with codes 81298, 81292, 81295, & 81317.
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. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 there is no support in the documentation that you require the intensive medical care 
and the intensive rehabilitation therapy program provided in an IRF. The medical records do not clarify that 
treatment at the skilled nursing facility level is not appropriate 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit services from an out-of-network (OON) 
provider be covered at the in-network benefit level. 
 
You asked the Plan to pre-approve the OON office visit services covered at the in-network benefit level. The 
Plan denied your request. The Plan says there are in-network providers who can provide the care needed. The 
Plan says that the enrollee can use your OON benefits, but there will be extra costs for their care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The rules say a plan 
must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for 
services obtained from a specialist who is out-of-network.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these services at the in-network level of benefits. Therefore, we decided that the Plan 
does not have to pre-approve office visit services from an out-of-network (OON) provider be covered at the in-
network benefit level.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99205) provided on January 21, 2021. 
 
You asked the Plan to pay for the physician service. You say that your other coverage was terminated as of 
December 31, 2020. You also say that this should be paid. The Plan denied your request. The Plan says that the 
claim processed correctly. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for the office visit (99205) provided on January 21, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the medical records 
support the need for inpatient behavioral health services. The Plan denied your request. The Plan says the 
enrollee's care can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee 
was admitted to the acute inpatient psychiatric hospitalization on September 14, 2022, with Unspecified 
Depressive Disorder, Posttraumatic Stress Disorder and Mixed Personality Disorder Including (Borderline and 
Dependent). Based upon review the records provided it was not expected this enrollee would improve in a 
reasonable period of time as she did not have dangerousness to self or others and was not showing any 
auditory/visual hallucinations or any aggressive behaviors. It did not appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care 
as she did not have dangerousness to self or others. It did not appear that the services were reasonably expected 
to improve the patients condition or for the purpose of diagnosis. 
 
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 psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit services provided by an out-of-network (OON) provider 
on May 24, 2022. 
 
You asked the Plan to pay for the office visit services provided by an OON provider. 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 when provided out-of-network. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees who receive Physician/Practitioner services in Puerto Rico must pay a 
10% coinsurance for covered services out-of-network under the Point of Service (POS) option. 
 
Based on this information, you are only responsible for a 10% coinsurance once the Plan has reprocessed the 
claim for payment. Therefore, we decided that the Plan has to pay for the office visit services provided by an 
out-of-network (OON) provider on May 24, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553) 
provided on April 3, 2022. 
 
You asked the Plan to pay for the CGM supplies. The Plan denied your request. The Plan says the 
documentation submitted did not sufficiently support the billed supply code. 
 
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. Medicare rules also say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
The record does not contain a valid proof of delivery with a tracking number showing that the item as 
delivered. Additionally, the documentation does not show that the treating practitioner has an in-person visit 
with the beneficiary to assess adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553) 
provided on April 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership from January 1, 2022, through March 31, 
2022. 
 
You asked the Plan to pay for a gym membership. You say that you want the Plan to reimburse you for the 
charges. The Plan denied your request. The Plan says in order to be reimbursed for the fitness benefit, you must 
use a participating facility. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only when you use a participating facility. 
 
The Plans rules for coverage of gym benefits have not been met because you must use a participating facility. 
Therefore, we decided that the Plan does not have to pay for a gym membership from January 1, 2022, through 
March 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on April 27, 2022. 
 
You asked the Plan to pay for the durable medical equipment. 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 supported. 
 
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 or relevant medical records which support medical 
necessity 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 
durable medical equipment provided on April 27, 2022.