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

 
We decided that the Plan does not have to pay for outpatient services (G0378, 80059) provided October 14, 
2021 to October 18, 2021. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT codes G0378, & 80059 are not supported in the medical record. Specifically 85009 has a 
bundled relationship with another code billed. Code G0378 (25 units) was not correctly billed. All units of this 
service must be billed on a single line. Based on this information, we decided that Medicare rules for coverage 
of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for 
outpatient services (G0378, 80059) provided October 14, 2021 to October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for COVID-19 vaccine administration (0001A) provided 
September 28, 2021. 
 
You asked the Plan to pay for the vaccination. You say that please issue immediate payment on this claim. 
Please note this is a COVID vaccine which has been approved by the federal government. The Plan denied your request. The Plan says Medicare payment for COVID vaccinations administered during calendar years 
2020 and 2021 to MA member will be made through the Medicare FFS program. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the vaccination have not been met. Therefore, we decided that the Plan does not have to pay for 
COVID-19 vaccine administration (0001A) provided September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lower 
extremity; without contrast (73702). 
 
You asked the Plan to pre-approve a CT scan of the lower extremity. You say that the requested CT scan is 
medically necessary. The Plan denied your request. The Plan says the requested CT scan does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the lower extremity. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is limited 
published, large-scale, long-term peer-reviewed literature that shows this request to be an effective and/or safe 
treatment for the noted pathology. Ultimate outcome differences regarding function and pain relief have not 
been noted to be significantly improved via this request in large volume long-term studies (over and above non- 
robotic assisted total knee arthroplasty.) 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 CT scan of the lower extremity have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) scan of the lower extremity; without 
contrast (73702).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 10, 2022. 
 
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 separately payable. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lower extremity strapping (29580) provided November 17, 
2021 to November 24, 2021. 
 You asked the Plan to pay for the lower extremity strapping. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the billed units exceed the allowed amount. 
 
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 29580 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 of the lower 
extremity strapping have not been met. Therefore, we decided that the Plan does not have to pay for lower 
extremity strapping (29580) provided November 17, 2021 to November 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are not happy with the skilled nursing facility 
you are currently in. The Plan denied your request. The Plan says that a decision was not rendered within the 
allotted time frame. 
 
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, a request for information was faxed to the Plan asking for medical 
records. The Plan has not forwarded any medical records. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to pre-approve acute inpatient 
rehabilitation facility (IRF) admission and services.  
 
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 inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for anemia and acute 
kidney injury. The enrollees medical problems are stable. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. 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 in a different level of care. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assisted living facility visit provided on December 8, 
2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the assisted living facility visit. You say that it is up to the staff to obtain the 
proper authorization and you would like the claim processed for payment. The Plan denied your request. The 
Plan says the rendering provider is an OON provider and there was no approved authorization. 
  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 the assisted living facility visit provided on 
December 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 
23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was sufficient information to manage the enrollee without definitive testing. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the medical record sent by the provider showed presumptive screening test results which were consistent 
with prescription medications, dosing schedules, or history and expected results. There was sufficient 
information to manage the enrollee without definitive testing. The review has determined that the enrollee did 
not require this drug testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing services provided to the enrollee on November 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the SelectMDx testing provided on December 23, 2021 
 
You asked the Plan to pay for the SelectMDx testing. You say that this is proprietary testing that cannot be 
provided by any other lab. The Plan denied your request. The Plan says this is not medically necessary for this 
patient. 
 
Medicare rules say that molecular diagnostic laboratory tests such as SelectMDx are subject to the MolDX 
application, assessment, and approval process. Once this is complete, the test is assigned a reimbursement rate 
and unique test identifier. 
 
We looked at the file and Medicare rules. The DEX Diagnostic Exchange lists this test as not covered by 
Medicare.  
 Based on this information, we decided that Medicare rules for coverage of the SelectMDx testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on December 
23, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of ophthalmologist services with an 
out-of-network (OON) provider. 
 You asked the Plan to pre-approve continuation of care services. You say that care with an OON provider 
continues to be medically necessary. The Plan denied your request. The Plan says there are in-network 
providers available for your medical needs. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 continuation of care services. Our 
reviewer says that the requested continuation of care with an OON provider is not medically reasonable and 
necessary. Our physician reviewer found you have diagnoses of Discoid lupus erythematosus of right eye, 
unspecified eyelid, Age-related nuclear cataract, bilateral, Miosis, and Dry eye syndrome of bilateral lacrimal 
glands. In this case, you do not wish to change to a new provider as you have been seeing the OON provider 
for several years. The documentation does not support that it is medically necessary for you to continue care 
with the out-of-network ophthalmology provider. Your care needs can be adequately met with an in-network 
Plan provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of care services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of ophthalmologist services with an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization administration (90471) and tetanus, 
diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided March 16, 2022. 
 
You asked the Plan to pay for the immunization. You say that you spoke to a Plan representative and they said 
you needed to go to a pharmacy to get vaccinated. The Plan denied your request. The Plan says this vaccination 
is not covered when billed with a non-covered diagnosis. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the immunization. 
Therefore, we decided that the Plan does not have to pay for the immunization administration (90471) and 
tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided March 16, 2022.  
 
Benefits for the immunization 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that records do not show a need for an intensive program with a team of 
health care professionals and doctors that specialize in complex medical needs or an interdisciplinary team 
approach to the delivery of rehabilitation 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for total hip 
replacement and had a fall with ankle fracture. The enrollees medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 in a different level of care. There is 
not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on 
December 23, 2021. 
 
You asked the Plan to pay for the services. You say that payment should be made at the maximum amount 
allowed. The Plan denied your request. The Plan says there was no documented contact with the 
attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided to the 
enrollee on December 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (99350) provided on January 19, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the 
services have been provided out-of-network and were not approved in advance. 
 
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 the home health services (99350) provided on 
January 19, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cardiovascular disease testing provided by 
an out-of-network (OON) provider on March 7, 2022. 
 
You asked the Plan to waive the deductible for the OON cardiovascular testing. You say that you were 
informed that the provider was in-network. The Plan denied your request. The Plan says the correct amount 
was applied to your deductible. 
 
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 there is $750 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Cardiovascular Disease 
Testing benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $750 deductible which applies to certain items and services. This cost sharing is a contractual obligation that 
had not been met at the time the OON cardiovascular testing was received on March 7, 2022. Therefore, we 
decided that the Plan does not have to waive the deductible for cardiovascular disease testing provided by an 
out-of-network (OON) provider on March 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from March 4, 
2021, to April 2, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the signed date on the plan of care is illegible. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
 
 
 
 
 
 
 
 
 The signature and date for the plan of care is illegible in this case. The closest date that it appears to 
approximate is 10/11/21, which would not make sense for the dates of service of service at issue in this case. 
Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from 
March 4, 2021, to April 2, 2021.