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

 
We decided that the Plan does not have to pay for the lab testing provided on February 26, 2021. 
 
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 billed with an inappropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab testing 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 testing provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that due to the enrollee's neurologic injuries, 
you feel her condition still warrants placement at a LTACH for further daily assessment of a medical 
practitioner, as well as respiratory therapy needs, along with continued physical and occupational therapy. The 
Plan denied your request. The Plan says the LTACH services you are requesting do not meet the requirements 
for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
 
  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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no evidence that the enrollee requires services that are not currently available. 
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the 
current ACH until such time no acute services are required.  Our physician reviewer also found that the 
enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care, provided on 
December 10, 2021, through December 23, 2021. 
 
You asked the Plan to pay for the SNF care. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the service was not medically necessary. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital the 
member had stabilized medically. The member did not require any skilled nursing or rehab services on a daily 
basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and 
predictable period of time or require skilled therapy to prevent deterioration with mobility or self-care tasks. 
The member did not require skilled therapy to establish a safe and effective maintenance program. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care, provided on December 10, 2021, through December 23, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan has to pay for ultrasonic guidance for needle placement (eg, biopsy, aspiration, 
injection, localization device), imaging supervision and interpretation (CPT code 76942) and insertion of non-
tunneled centrally inserted central venous catheter; age 5 years or older (CPT code 36556) provided on August 
10, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 asked our coder 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 found the reviewed 
documentation indicates that code CPT 76942 was supported as a surgeon requested a post-operative pain 
block, but code 36566 would require an appropriate modifier to override the edit and is supported per 
documentation submitted. The review indicates that the codes were supported in the medical records. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 
supervision and interpretation (CPT code 76942) and insertion of non-tunneled centrally inserted central 
venous catheter; age 5 years or older (CPT code 36556) provided on August 10, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on August 2, 2021. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says the enrollee was on hospice on the date of service in 
question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. The Plan denied your request. The Plan says you must receive your care from a network provider. In 
most cases, care you receive from an out-of-network provider (a provider who is not part of our Plans 
network) will not be covered. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on July 27, 2021. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says the enrollee was on hospice on the date of service in 
question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on July 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs the bed due to her conditions. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223) provided on January 5, 2020. 
 
You asked the Plan to pay for the evaluation and management service. You say that the timeframe to submit 
health claims has been extended to 60 days after the announcement of the end of the current National 
Emergency. You say that the Public Health Emergency is still ongoing and has continued to be renewed 
nationwide. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the evaluation and management service was not filed until March 24, 2021. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Additionally, the services in this case were rendered prior to the Public Health Emergency.  
  
Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on 
January 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for at-home COVID-19 self-tests purchased on December 30, 
2021. 
 
You asked the Plan to pay for at-home COVID-19 self-tests. You say that these tests are necessary, and you 
were told you could receive reimbursement on this claim. The Plan denied your request. The Plan says these 
tests are considered an over-the-counter item and were not covered by Medicare or your Plan on the date of 
purchase. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and at-home 
COVID-19 self-tests are an OTC item. Therefore, we decided that the Plan does not have to pay for at-home 
COVID-19 self-tests purchased on December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 5, 
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 provider did not submit progress notes in order to determine the clinical utility of this 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 reviewed documentation indicates that the provider did not submit progress notes that are needed in 
order to determine the clinical utility of the testing. The review has determined that the enrollee does not meet 
the criteria for this 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 August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing provided to the enrollee on 
November 12, 2021. 
 
You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your 
request. The Plan says it cannot be determined how the enrollee came to the servicing provider, or whether 
services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found given the documentation provided for review, it cannot be determined how the enrollee came to the 
servicing provider or whether the services are medically necessary. Non-participating providers are required to furnish necessary information to the health plan when requested. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne CDx testing provided to the enrollee on November 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services provided from October 6, 2021, to 
October 21, 2021, outside of the United States. 
 
You asked the Plan to pay for the therapeutic services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the therapeutic services that you received outside of the United States 
were not urgent or emergent in nature. The Plan also says that the services could have been provided in 
network. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to 
pay for the therapeutic services provided from October 6, 2021, to October 21, 2021, outside of the United 
States.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 5, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
emergency medical technicians strongly suggested you not go to the emergency room by ambulance because 
the hospital had an excessive number of COVID-19 cases at the time. You also say that you were urged to 
travel by a personal car to a local urgent care instead. The Plan denied your request. The Plan says your plan 
covers ambulance transportation only when you are actually transported by ambulance. The Plan also says that 
since you were not transported by ambulance, the service is not covered under your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on August 5, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that your daughter was contacted and said she would take you to a less busy facility with less 
risk of COVID-19 exposure. The documentation shows you signed a refusal denying transportation by the 
ambulance. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment 
with no transport (A0998) provided on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided November 1, 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 the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes 
a single procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were billed for the same panel performed 
on the same specimen. Another claim was submitted with multiple other lab codes for the same specimen. 
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (81479) provided November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent ambulance transportation services (A0428-
HR, A0425-HR) provided on June 5, 2021. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary, as the 
enrollee was too weak to sit up in a wheelchair due to an infection and had to be taken on a stretcher. The Plan 
denied your request. The Plan says these services were not medically necessary or were not billed correctly. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance services. Our reviewer says that 
the ambulance transportation was not medically necessary on the date in question as defined by Medicare 
criteria. Our physician reviewer found that while the records indicate that the enrollee was too weak to 
ambulate or sit up in a wheelchair, there is no documentation to report that transport by a stretcher van was 
contraindicated. There is no documentation to show that the enrollee required the expertise, services and 
lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on 
June 5, 2021. Other than the weakness that was reported, the records do not report any unstable vital signs or 
finding on physical assessment or need for isolation or cognitive or behavioral issues which would have 
prevented safe transport by a stretcher van. Therefore, there is insufficient documentation to show that the ambulance transport on the date in question was medically reasonable and necessary as defined by Medicare 
criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that the Plan does 
not have to pay for non-emergent ambulance transportation services (A0428-HR, A0425-HR) provided on June 
5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided 
December 23, 2021. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you needed an additional x-ray for further 
evaluation. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the panoramic 
x-ray once every three plan years. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray 
was previously covered on August 18, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the panoramic x-ray has been exceeded. Therefore, we decided that the Plan does not have 
to pay for the panoramic radiographic image (D0330) provided December 23, 2021.