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

 
We decided that the Plan does not have to pay for inpatient hospital care provided from April 3, 2022,  
to April 5, 2022. 
 
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 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 inpatient hospital care provided from April 3, 2022, to  
April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (73030, 73070, 73502) and a computed tomography 
scan (72125) provided on June 11, 2022. 
 
You asked the Plan to pay for x-rays and a computed tomography scan. You say that these services were 
medically necessary. The Plan denied your request. The Plan says these services are not separately. 
 The Plan must follow Medicare rules. Medicare rules say that if a claim includes a service that is assigned 
status indicator S, T, or V reported on the same claim as a service with status indicator Q1, indicating a STV- 
packaged service, the payment for the service with status indicator Q1 is packaged into the payment for the 
service(s) with status indicator S, T, V and no separate payment is made for the service with status indicator 
Q1. A service that is assigned to a composite ambulatory payment classification (APC), indicated with status 
indicator Q3, is a major component of a single episode of care. The hospital receives one payment through a 
composite APC for multiple major separately identifiable services.  
 
We looked at the file and Medicare rules. The codes used to report the x-ray services have a status indicator of 
Q1 and were reported with 99284, which has a status indicator of V, which means the x-ray services are not 
separately payable. The computed tomography scan has a status indicator of Q3, meaning it is also not 
separately payable. Based on this information, we decided that Medicare rules for coverage of x-rays and a 
computed tomography scan have not been met. Therefore, we decided that the Plan does not have to pay for x-
rays (73030, 73070, 73502) and a computed tomography scan (72125) provided on June 11, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on August 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was under 
the hospice benefit on the date 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 the ambulance services provided on August 28, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care provided on December 30, 2021. 
 
You asked the Plan to pay for subsequent hospital care. The Plan denied your request. The Plan says the 
member was in hospice care on this date of service. Therefore, the claim is the responsibility of traditional 
Medicare. 
 
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 subsequent hospital care provided on December 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI), also known as a 
nuclear stress test. 
 
You asked the Plan to pre-approve the requested MPI. You say that it is felt that this testing is necessary to 
evaluate the enrollee's condition. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that stress testing with imaging may be covered when 
reasonable and necessary for certain conditions.  
 
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 requested MPI. Our reviewer says 
that the documentation does not support that there is a medically necessary indication for this testing. Our 
physician reviewer found the enrollee has a history of orthostatic dizziness. He has a pacemaker and presents 
no cardiac symptoms. There is no documentation that the ECG shows an uninterpretable pattern. There is no evidence provided that would support the need for radionuclide stress testing. As a result, at this time 
radionuclide stress testing would not be considered medically necessary in this enrollee's 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 requested MPI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myocardial perfusion imaging (MPI), also known as a nuclear stress test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coronary angiography to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve coronary angiography. You say that this is necessary. The Plan denied your 
request. The Plan says this provider is out-of-network with the Plan and the enrollee can be treated within the 
Plan network. 
 
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 
coronary angiography to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery backup for a nebulizer machine. 
 
You asked the Plan to pre-approve battery backup for a nebulizer machine. You say that this is necessary for 
frequent power outages. The Plan denied your request. The Plan says a battery backup for a nebulizer machine 
is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery serves the same purpose as equipment already available to you. Therefore, we decided that 
the Plan does not have to pre-approve battery backup for a nebulizer machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on June 16, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says there is no evidence to 
support the ordering provider is treating the enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that a written order/prescription is a written 
communication from a treating practitioner that documents the need for a beneficiary to be provided an item of 
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). All DMEPOS items require a 
written order/prescription from the treating practitioner for Medicare payment as a condition of payment. 
 
We looked at the file and Medicare rules. The submitted documentation does not show that the DME was 
ordered by the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment (DME) provided on June 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for therapy visit and surgical service provided 
on July 24, 2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for therapy visit and surgical service. You say that you are 
disputing the share cost. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment for outpatient substance abuse services and $175 for outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay $10 copayment for therapy visit and $175 for surgical service. These items/services fall within the outpatient substance abuse services and outpatient surgery, including services 
provided at hospital outpatient facilities and ambulatory surgical centers benefit categories. 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 therapy visit and surgical service provided on July 24, 2022, to July 
26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on June 9, 2022 
 
You asked the Plan to waive the copayment for x-ray. You say that you are disputing the share cost. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $30 copayment for x-ray. This item/service falls within the outpatient diagnostic 
tests and therapeutic services and supplies 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 x-ray provided on June 9, 2022
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis (Tdap) 
vaccine provided on June 6, 2022. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this vaccine is not among those covered 
under your medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis (Tdap) vaccine provided on June 6, 2022.  
 
Benefits for the Tdap vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic shoes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology (high-grade prostate cancer), biochemical 
assay of four proteins, utilizing plasma or serum, prognostic algorithm reported as a probability score (81539). 
 
You asked the Plan to pre-approve genetic testing. You say that you have a brother with a past diagnosis of 
prostate cancer. The testing is necessary. The Plan denied your request. The Plan says the requested biomarker 
testing is denied as not being covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There is no supporting documentation to render the request of 
Biomarker testing medically necessary. You are to have a trans rectal ultrasound guided prostate biopsy in the 
near future, and it is confirmed that a request for a pelvic MRI has been approved. 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 pre-approve an oncology (high-grade prostate cancer), biochemical assay of four 
proteins, utilizing plasma or serum, prognostic algorithm reported as a probability score (81539).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic activities (97530). 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 these services.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that according to Medicare a service is medically 
reasonable and necessary if it is safe and effective and not mainly for the convenience of the patient or the 
physician. In order to be considered medically necessary a service cannot be investigational or experimental 
and must be ordered by qualified personnel and be appropriate to the patients medical needs and condition.  
Additionally, there must be an appropriate duration and frequency that is appropriate for the service. In this 
case, you have been previously treated with outpatient therapies and should be independent with a home 
exercise program. There is no documentation of a recent injury or decline in function. The additional therapy 
services are not an appropriate duration and frequency for treatment of your medical condition and therefore 
are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic activities (97530).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
July 22, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service July 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 19, 2022. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the 
member was in hospice on this date of service. The claim should be billed to traditional Medicare. 
 
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 subsequent nursing facility care provided on May 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Victoza. 
 
You asked the Plan to pre-approve Victoza. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Victoza.  
 
  Benefits for Victoza 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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve a spinal cord stimulator. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the 
requested spinal cord stimulator. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve a spinal cord 
stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary, and the enrollee can safely receive the services they need in other settings. 
 
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 that the enrollee's functional status does not require intensive rehabilitation services 
to regain function. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 13, 2022, billed with 
codes 81162, 81201, 81209, 81218, 81292, 81295, 81292, 81295, 81298, 81307, 81321, 81334, 81351, 81406, 
81437, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
Additionally, the Plan says that there is no documentation stating how this test will directly impact treatment. 
 
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 
June 13, 2022, billed with codes 81162, 81201, 81209, 81218, 81292, 81295, 81292, 81295, 81298, 81307, 
81321, 81334, 81351, 81406, 81437, and 81479.