Persius/hicric huggingface dataset:
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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
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 the enrollee 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 not a reasonable expectation that the 
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
 
 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 Ozempic.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional skilled nursing home health visits. 
 
You asked the Plan to pre-approve additional skilled nursing home health visits. You say that the requested 
additional skilled nursing home health visits are medically necessary. The Plan denied your request. The Plan 
says the requested additional skilled nursing home health visits do not meet criteria. 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional skilled nursing home health 
visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
inadequate documentation that additional skilled nursing services are required to effectively provide treatment, 
care, and/or services in order to improve your condition, or to establish/perform a maintenance program to 
maintain your condition and/or prevent deterioration. Provided records are inadequate to document the need for 
further skilled nursing visits beyond the six visits that have already been approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing home health visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve six (6) additional skilled nursing home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dialysis services. You say that you would like to continue your treatment at 
the same facility. The Plan denied your request. The Plan says the requesting facility is now an OON provider 
and the transition to a contracted facility was done 90 days prior to the end of the contract. The contracted 
provider is within 20 minutes from the enrollee's home and services have been arranged for the same exact 
days and shifts. 
 
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 
dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac implanted loop record (ILR). 
 
You asked the Plan to pre-approve the cardiac ILR. You say that this is medically necessary to evaluate the 
patient's condition. The Plan denied your request. The Plan says the enrollee has had no symptoms to require 
implanted heart monitoring. 
 
The Plan follows Medicare rules. Medicare rules say that AECG, including ILR, may be reasonable and 
necessary to evaluate symptoms may correlate with intermittent cardiac arrhythmias and/or myocardial 
ischemia. 
 
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 cardiac ILR. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary. Our physician reviewer found 
the enrollee is a 70-year-old man with history of asymptomatic bradycardia and third-degree atrioventricular 
block. There is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this patients clinical management. 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 cardiac ILR have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cardiac implanted loop record (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on January 21, 
2022. 
 
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 this was not reported correctly. 
 
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 67904 is 1. The MAI value for this code is 2. You billed two units of this 
code, exceeding the MUE. 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 surgical services 
provided to the enrollee on January 21, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 28, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service February 28, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 10, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 February 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 16, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says 
they have also determined that these services are not urgent or emergent, nor were they 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 an office visit provided on February 16, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an incontinence garment provided to the enrollee on 
December 8, 2021. 
 
You asked the Plan to pay for the item. You say that this should be paid for. The Plan denied your request. The 
Plan says this service is not covered by Medicare. 
 
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 pay for an incontinence garment provided to 
the enrollee on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care services provided on March 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care services. You say that you have corrected the claim for 
processing. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
are in-network providers who could have provided the same 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 the nursing facility care services provided on 
March 3, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the various services provided to the enrollee on January 14, 
2022. 
 
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 bill as required by Medicare coding regulations. 
 
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 99070 and 36000 have a status indicator of B on the Physician Fee Schedule. This 
means that CPT code 99070 and 36000 is not separately payable.  
 
We find that procedure code A4649 has a status indicator of "P" which also means that it is bundled into 
payment for other services. 
 
We find that CPT 93041 is a column II code to the column I code 62323. An appropriate modifier was not 
billed to bypass this code edit. 
 
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 various services provided to the enrollee on 
January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel test coded as 81206, 81235 and 
81321 provided April 19, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration of this 
determination and cover the Tempus Gene Panel test at the in-network benefit level. The Plan denied your 
request. The Plan says does not meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code 81206, 81235 and 81321 is not supported in the medical record. 
Specifically, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. 
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural 
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare 
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Tempus Gene Panel test coded as 81206, 81235 and 81321 provided April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on April 20, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says prior 
authorization was not obtained by the provider or facility. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for chiropractic treatment provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FANCC genetic testing provided on October 31, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the MolDX Team has determined that testing for 
the FANCC is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, 
MolDX will also deny panels of tests that include the FANCC gene.  
 
We looked at the file and Medicare rules. Per LCA A53628, the requested FANCC genetic testing is not a 
covered benefit. 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 FANCC genetic testing provided on 
October 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for breast biopsy provided on November 24, 
2021. 
 
You asked the Plan to waive the copayment for breast biopsy. You say that you are on a fixed income and 
cannot afford the copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $250 
copayment per day for outpatient procedures and services, including, but not limited to, outpatient surgery 
performed in an outpatient hospital or ambulatory surgical center.  
 
 
 
 You have been asked to pay $250 copayment for breast biopsy. Breast biopsys fall within the Outpatient 
hospital 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 waive the copayment for breast biopsy 
provided on November 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a muscle imaging scan provided to the enrollee on February 
24, 2021. 
 
You asked the Plan to pay for thee. You say that this should be paid for. The Plan denied your request. The 
Plan says on the date of service, the plan was the secondary payer. 
 
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 met its obligation with regards to coordination of benefits. Specifically, the Plan has reached out 
to the provider to inform them another insurance was the primary payer. The requested Explanation of Benefits (EOB) from the primary plan was not received. As the secondary 
insurer, the Plan cannot be held responsible for thee until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for a muscle imaging scan provided to the 
enrollee on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary/rest home visit provided to the enrollee on 
October 27, 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 authorization was not 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 a domiciliary/rest home visit provided to the 
enrollee on October 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services are covered and this claim should be 
paid. 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 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 August 17, 2021.