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

 
We decided that the Plan does not have to pay for laboratory services (81455) provided on April 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for out-of-network laboratory services. You say that this testing was medically 
necessary and was referred by a physician. The Plan denied your request. The Plan says the requested services 
were performed by an out-of-network laboratory and referred by an out-of-network provider. Out-of-network 
care is only covered in certain limited circumstances which have not been met in this case. 
 
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/referred 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 laboratory services (81455) 
provided on April 1, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab tests for prescribed drugs and drugs of 
abuse. The Plan denied your request. The Plan says the billed codes cannot be verified. 
 The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. The testing described by billed code 83789 is 
considered specimen validity testing which is not separately payable. 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 provided on March 9, 2022.
Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to provide reimbursement for the transplant-related travel and lodging expenses 
provided from February 20, 2022, to May 26, 2022. 
 
You asked the Plan to provide reimbursement for the transplant-related travel and lodging expenses. You say 
that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says 
that the services are not covered. 
 
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. The Plan states this cannot be paid because the services were non-transplant 
related. No evidence of this was provided. You were seen at a distant location for care related to aftercare for a 
lung transplant. This is documented for each date of service at issue in this appeal in the medical records 
provided for review. Therefore, we decided that the Plan has to provide reimbursement for the transplant-
related travel and lodging expenses provided from February 20, 2022, to May 26, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services provided to the enrollee on March 18, 2022. 
 
You asked the Plan to pay for the services. You say that this was requested by the enrollee's primary care 
physician. The Plan denied your request. The Plan says that there are several in-network providers who could 
have rendered this service. 
 
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 the services by a contract provider - your primary care physician. The file does not show 
that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the 
services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory 
services provided to the enrollee on March 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on February 21, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test identifies possible treatment options. 
The Plan denied your request. The Plan says the unique test identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim provided does not show the test was reported per billing guidelines. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on February 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 13, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test identifies possible treatment options. 
The Plan denied your request. The Plan says the unique test identifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. The claim information does not show that the testing was billed as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the lab testing services provided on April 13, 2022.
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 you are appealing the denial of authorization for 
acute inpatient rehabilitation admission. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet the requirements for 
approval. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a 
need for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. The enrollee can receive further services at a lower 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from September 24, 2021, 
through September 27, 2021, at DRG 190. 
 
You asked the Plan to pay for the inpatient services at DRG 190. You say that this condition was evaluated, 
treated, and monitored for improvement and there is sufficient documentation support the diagnosis. You say 
that removing the diagnosis would be inappropriate and the claim should be paid as originally submitted. The 
Plan denied your request. The Plan says secondary diagnosis code J96.20 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.20, defined as acute 
and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia. 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 inpatient services at DRG 190. Our reviewer says that the 
documentation does not support secondary diagnosis code J96.20. Our physician reviewer found while the 
physician documented the diagnosis of acute respiratory failure with hypoxia, the diagnosis was not sufficiently 
supported by the medical record documentation.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from September 24, 2021, through September 27, 2021, at DRG 190.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of the members nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment 
by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. The member continues to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that she would meet criteria 
for admission to an acute inpatient rehabilitation facility. The member can receive further services at a lower 
level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
IRF 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that a lack of therapy will lead to an inability to walk. 
The Plan denied your request. The Plan says that a total of 20 visits have already been approved. 
 
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 the visits. Our reviewer says that the 
requested visits are medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation shows that you are still requiring use of a quad cane, and have difficulty negotiating steps. Not 
all of the reasonable therapy goals have been met; therefore, the ten additional sessions are 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 the visits have been met. Therefore, we decided that the Plan has to pre-approve 
ten additional physical therapy visits.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided on February 23, 2022. 
 
You asked the Plan to pay for genetic testing. You say that you want the Plan to pay for the service. The Plan 
denied your request. The Plan says the claim did not contain a Dex-Z code unique identifier which is required 
by Medicare.  
The Plan must follow Medicare rules. Medicare rules say that tests approved through the MolDX program must 
be billed with the unique test identifier.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, tests approved through the MolDX program must 
be billed with the unique test identifier, and this claim does not include that identifier. Therefore, we decided 
that the Plan does not have to pay for genetic testing (0037U) provided on February 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation. 
 
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 medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulation is covered when 
specific criteria are met. 
 
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 
the services are not medically necessary. Our physician reviewer found the records document the enrollee tried 
continuous positive airway pressure (CPAP) therapy four years ago with various masks but did not tolerate it 
and has not been using CPAP therapy for the past four years. The records do not document shared decision 
making that she is intolerant of CPAP, despite consultation with a sleep expert. The criteria for coverage are 
not met; therefore, the hypoglossal nerve stimulation 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hypoglossal nerve stimulation.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the injection (96375), collection of venous blood (36415), 
comprehensive metabolic panel (80053), magnesium (83735), and lorazepam (J2060) provided on March 8, 
2022. 
 
You asked the Plan to pay for the physician and laboratory services. You say that you have a valid 
authorization for the date of service. The Plan denied your request. The Plan says that prior authorization was 
not obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file does not support the Plan's denial. Therefore, we decided 
that the Plan has to pay for the injection (96375), collection of venous blood (36415), comprehensive metabolic 
panel (80053), magnesium (83735), and lorazepam (J2060) provided on March 8, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Inspire, cranial nerve neurostimulator electrode array 
and pulse generator (64582, C1767). 
 
You asked the Plan to pre-approve cranial nerve neurostimulator electrode array and pulse generator. You say 
that the device is medically necessary. The Plan denied your request. The Plan says the request to authorize a 
nerve stimulator implant for your sleep apnea is denied as not 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 pre-approve cranial nerve neurostimulator electrode 
array and pulse generator. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the record indicates that you have sleep 
apnea. The record indicates the performance of a drug induced sleep endoscopy that demonstrates complete 
collapse of the soft palate. The record provided does not establish the medical necessity and reasonableness, as 
defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The 
requested service is not recommended. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cranial nerve neurostimulator electrode array and pulse generator have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an Inspire, cranial nerve neurostimulator 
electrode array and pulse generator (64582, C1767).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus xT Solid Tumor & Heme CGP panel (81455) 
billed for date of service April 4, 2022.  
You asked the Plan to pay for genetic testing. 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 because the 
services at issue were billed with the incorrect DOS. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS of the test/service must be the date the 
specimen was collected. If the specimen was stored for more than 30 calendar days before testing, the specimen 
is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained 
from storage. 
 
We looked at the file and Medicare rules. In this case, the available records document that the specimen was 
stored for more than 30 calendar days before testing. The records indicate that the specimen was obtained from 
storage on March 24, 2022. The services at issue were billed incorrectly with the date of testing. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for a Tempus xT Solid Tumor & Heme CGP panel (81455) billed for 
date of service April 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this procedure is considered experimental. More research is needed to show safety 
and efficacy. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genetic profiling (81455) provided on 
November 2, 2021. 
 
You asked the Plan to pay for genetic testing. You say that this is a medically necessary test which is covered 
by Medicare. The Plan denied your request. The Plan says this test was not billed in accordance with Medicare 
rules, as the required DEX Z-Code is missing from this claim. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for comprehensive genetic profiling (81455) provided on 
November 2, 2021.