Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the counseling services provided to the enrollee from 
December 8, 2021, to March 7, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the member did not 
submit an itemized bill to complete the reimbursement request. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the counseling services provided to the 
enrollee from December 8, 2021, to March 7, 2022. have been met. The Plan requires documentation showing 
the services that were provided, diagnosis, dates of service, and who they were provided by, in order for 
payment to be considered. This documentation was not submitted to the Plan.  Therefore, we decided that the Plan does not have to pay for the counseling services provided to the enrollee 
from December 8, 2021, to March 7, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99153) provided on March 31, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a 
practice expense (PE) only code and is not paid in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. 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 the services (99153) provided on March 31, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home healthcare services provided form November 30, 2021, to 
December 29, 2021. 
 
You asked the Plan to pay for the home healthcare services. The Plan denied your request. The Plan says that a 
RAP claim was not billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the documentation submitted does not include any evidence to 
support why this claim was denied. The file includes a Request for Anticipated Payment (RAP) and there is no 
indication of a discrepancy between the dates of service at issue. The Plan has not clearly stated why these 
claims are not valid. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, 
the Plans denial is not substantiated so we must find in your favor. Therefore, we decided that the Plan has to 
pay for the home healthcare services provided form November 30, 2021, to December 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence garments and disposable underpads. 
 
You asked the Plan to pre-approve the supplies. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not covered by Medicare or the health plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence garments and 
disposable underpads.
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 say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness, falls, and hyperglycemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on April 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this was ordered by an OON provider, and no authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 lab testing provided on April 23, 2021, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request does not meet the coverage requirements. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has a diagnosis of  adenocarcinoma of the lung.  The record indicates that the enrollee has been 
receiving the requested medication since June 2019, greater than the 24 months indicated according to 
Medicare compendia. The Food and Drug Administration has not stated that the requested drug is indicated for 
the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a supportive citation 
for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare-approved 
cancer journals were submitted for review. The elements of the coverage criteria are not satisfied. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. 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 the lab services provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 22, 2021, billed with 
codes 81206, 81235, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 22, 2021, billed with codes 81206, 81235, and 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasonic guidance for radiation therapy (G6001). 
 
You asked the Plan to pre-approve ultrasonic guidance for radiation therapy. You say that the requested service 
is a medical necessity for you. The Plan denied your request. The Plan says medical-necessity rules have not 
been met because the requested service is experimental/investigational. 
 
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 ultrasonic guidance for radiation 
therapy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found there is insufficient data available in the case record to 
justify medical necessity. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ultrasonic guidance for radiation therapy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ultrasonic guidance for radiation therapy (G6001).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda, Carboplatin, Paclitaxel protein-bound 
particles, Dexamethasone sodium phosphate for the enrollee. 
 
You asked the Plan to pre-approve the regimen. You say that this is medically necessary for the treatment of 
lung cancer. The Plan denied your request. The Plan says both the clinical guidelines and the step therapy 
requirements have not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 regimen. Our reviewer says that the 
requested drug regimen is not medically reasonable or necessary. Our physician reviewer found that the plan 
requires a trial of Taxol or Taxotere before they will approve the Abraxane/Paclitaxel. In this case, the patient 
has not tried and failed the required drug. There is no documentation provided indicating that the plans 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 regimen have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda, Carboplatin, Paclitaxel protein-bound particles, Dexamethasone sodium 
phosphate for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair provided to you on December 22, 2021. 
 
You asked the Plan to pay for the wheelchair. The Plan denied your request. The Plan says this provider is not 
certified by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the wheelchair provided to you on 
December 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology gene expression profiling (81529) provided on 
November 19, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this testing is a covered benefit which was 
medically necessary for this enrollee. The Plan denied your request. The Plan says this test was not billed in 
accordance with Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report melanoma risk stratification molecular testing in the state where this test was provided, 
the appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for oncology gene expression profiling (81529) provided on 
November 19, 2021.
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 say that this is medically necessary. The Plan denied your 
request. The Plan says needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness, falls, and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
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 pay for an office visit provided on January 13, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the member's plan excludes coverage for this out-of-network service. 
 
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 an office visit provided on January 13, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 29, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. 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 July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for chiropractic services provided from February 15, 
2022, through May 18, 2022. 
 
You asked the Plan to waive the cost for chiropractic services. You say that you were told your insurance was 
accepted and you would pay up front then submit for a refund. You say that you want to know what you are to 
pay for each appointment. The Plan denied your request. The Plan says the claims should have denied in full 
but were processed under the in-network chiropractic benefit. The Plan also says future chiropractic services 
should be received from in-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 there is a $125 
deductible which applies chiropractic services. You must pay a $20 copayment for each in-network, Medicare-
covered visit once the deductible is met. 
 
You have been asked to pay the in-network cost for the chiropractic services until your out-of-pocket 
maximum was met. This includes the allowed amount applied toward the deductible and $20 copayments for 
certain visits. The x-ray denied in full as it is not a covered chiropractic service. The chiropractic services fall 
within the Chiropractic Services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost for chiropractic 
services provided from February 15, 2022, through May 18, 2022.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on February 17, 2022. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that it failed to render a decision within the required time frames. 
 
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, in the Plan's clinical review notes, it explicitly states that these 
services met criteria for payment.  There is no evidence that the Plan has issued payment for these services at 
this time.  The Plan has provided no other evidence of why these services would be denied. Therefore, we 
decided that the Plan has to pay for medical services provided on February 17, 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.