Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to hold you harmless for outpatient rehabilitation services provided from January 
18, 2022, to February 21, 2022. 
 
You asked the Plan to hold you harmless for outpatient rehabilitation services. You say that your primary care 
provider referred you for these services and services have been approved and paid by the Plan in the past. The 
Plan denied your request. The Plan says that the denial of payment for these services is correct, because the 
Plan did not receive supporting records to determine medical necessity. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
You were referred for outpatient rehabilitation services by a contract provider. The file does not show that the 
plan provided notice that outpatient rehabilitation services would not be covered. Under Medicare rules, this 
means outpatient rehabilitation services are considered approved by the plan. Therefore, we decided that the 
Plan has to hold you harmless for outpatient rehabilitation services provided from January 18, 2022, to 
February 21, 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home COVID-19 self-tests purchased on January 15, 2022, 
from a non-participating online-retailer. 
 
You asked the Plan to pay for home COVID-19 self-tests. You say that these items were necessary and should 
be covered by your benefit. The Plan denied your request. The Plan says this item was purchased from a non-
participating retailer. Your supplemental benefit only works when you purchase OTC items from the specified 
vendor/a participating retailer. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and home 
COVID-19 self-tests is an OTC item which was not covered by Original Medicare on the date of purchase. The 
Plan offers a supplemental benefit to cover some OTC items. This benefit allows you to use your plan card to 
purchase eligible OTC items in-store at participating retail locations. Non-eligible items or items purchased at 
non-participating retail locations will not be covered. Only the Plans specified online retailer/vendor may be 
used for online orders. 
 
We looked at the file and the Plans rules. The provider in this case is not one of the Plans specified vendors or 
a participating retailer. Based on this information, we decided that the Plans rules for coverage of COVID-19 
self-tests are not met. Therefore, we decided that the Plan does not have to pay for home COVID-19 self-tests 
purchased on January 15, 2022, from a non-participating online-retailer.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 pre-approve SNF care. Our physician reviewer 
found the enrollee does not have any parental medication; complex wound care or nutrition given via a feeding 
tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The 
enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. 
Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on February 16, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to pay the claim 
under a prior authorization. The Plan denied your request. The Plan says the rendering provider is an OON 
provider and there was no referral from an in-network provider or an approved authorization. Also, the 
authorization requested does not fall under the same date of 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 home health services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 6, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance was 
necessary. The Plan denied your request. The Plan says the enrollee has been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each one-way ambulance trip.  
 
The enrollee has been asked to pay a $225 copayment for the ambulance transportation. The ambulance 
transportation falls within the Ambulance Services benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for ambulance transportation provided on March 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on 
August 27, 2021. 
 
You asked the Plan to pay for hospital discharge day management (99239). You say that the correct coding was 
assigned and no coding changes are required. You say that the services were medically necessary, and the 
medical records support the claim as originally billed. The Plan denied your request. The Plan says the records 
submitted do not support hospital discharge management of more than 30 minutes was performed. 
 
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, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
  We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
document hospital discharge management services of 30 minutes or more as required by the CPT code billed. 
Based on this information, we decided that Medicare rules for coverage of hospital discharge day management 
(99239) have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day 
management (99239) provided on August 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on January 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says services from non-participating providers are not covered unless 
preauthorized. 
 
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 psychotherapy provided on January 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on February 
7, 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 testing for the FANCC gene is a statutorily excluded service. 
 
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 that the case file does not contain documentation that demonstrates that the enrollee in this case has not 
been previously tested with the same test using NGS for the same cancer genetic content and has decided to 
seek further cancer treatment (e.g., therapeutic chemotherapy). 
 
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 genetic testing services provided to the enrollee on February 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve readmission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve readmission to a SNF. You say that the requested readmission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the requested readmission to a SNF does not 
meet criteria. 
 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 pre-approve readmission to a SNF. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found you received oral medications, 
had stable vital signs and was at a standby assist level for functional mobility including gait to 00 feet. You do 
not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity 
of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of readmission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve readmission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the wound dressings provided on February 3, 2022, 
through March 4, 2022. 
 
You asked the Plan to hold you harmless for the wound dressings. You say that you feel this should be covered. 
The Plan denied your request. The Plan says that this claim had cost sharing correctly applied. Medicaid pays 
for the cost sharing and must be billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the wound dressings by a contract provider. The file does not show that the Plan 
provided notice that the wound dressings would not be covered. Under Medicare rules, this means the wound 
dressings is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for 
the wound dressings provided on February 3, 2022, through March 4, 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.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for subsequent hospital care (99232) provided on September 15, 2021. We 
decided that the Plan does not have to pay for subsequent hospital care (99231), provided on September 16, 
2021.  
 
You asked the Plan to pay for subsequent hospital care. You say that this care was medically necessary and is 
eligible for separate payment. The Plan says that this provider billed for and was paid for other services which 
conflict with the services at issue. We decided that the Plan has to pay for subsequent hospital care (99232) provided on September 15, 
2021.  
 
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, no evidence of conflicting services was provided for the subsequent 
hospital care provided on September 15, 2021. The Plan has provided no clear argument as to why these 
services should not be covered, and the Plan has provided no documentation to substantiate an argument for the 
denial of this service. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) 
provided on September 15, 2021.  
 
We also decided that the Plan does not have to pay for subsequent hospital care (99231) provided on 
September 16, 2021. 
 
The rules say that A/B MACs (B) do not pay for both a subsequent hospital visit in addition to hospital 
discharge day management service on the same day by the same physician. Only the hospital discharge 
management code is to be paid for the day of discharge (unless it is also the day of admission). 
 
We looked at the file and Medicare rules. The documentation provided includes a claim for hospital discharge 
day management services (99238) which were provided to this enrollee on September 16, 2021, by the same 
provider who rendered the subsequent hospital services at issue. The claim for discharge day management 
services has been paid by the Plan. Therefore, we decided that the Plan does not have to pay for subsequent 
hospital care (99231) provided on September 16, 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services received on December 16, 2021. 
 
You asked the Plan to pay for the services. You say that the doctor only wrote a prescription. The Plan denied 
your request. The Plan says this code is not covered. 
 
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 procedure code H0032 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code H0032 is not valid for Medicare purposes. 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 mental health services received on December 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular pathology procedure; physician interpretation and 
report (G0452) provided on February 8, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that medical records documenting all billed 
units are attached. Providing evidence of their medical necessity. Please review and reprocess for payment. The 
Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 
providers require prior authorization before services being rendered. 
 
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 molecular pathology procedure; physician 
interpretation and report (G0452) provided on February 8, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) provided 
February 11, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please review the attached medical records 
that support that 81455 being medically necessary. The Plan denied your request. The Plan says targeted 
genomic sequence analysis panel, code 81455, is non-covered by Medicare. 
 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 looked at this the file, and Medicare rules. Per Local Coverage Article Billing and Coding Billing and 
Coding: Molecular Pathology Procedures A56199, 81455 is unlikely to impact therapeutic decision-making in 
the clinical management of the patient and will be denied automatically as not medically necessary. Based on 
this information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel (81455) 
provided February 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of the chest (71045) provided on November 11, 
2021. 
 
You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed with an 
appropriate modifier as required by Medicare billing 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. In this case, we have confirmed that code 71045 
is a column II code to column I code 36573. 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 the X-ray of the chest (71045) provided on November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (00790) provided on September 27, 2021. 
 
You asked the Plan to pay for anesthesia services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, anesthesia services were billed with place of service code 21 indicating an inpatient hospital. We 
find that place of service code 21 is not supported in the medical record. Specifically, the Plan has documented 
that the facility claim corresponding to the services at issue was billed as outpatient services, not inpatient.  
 
 
 
 Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been 
met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00790) provided on 
September 27, 2021.