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

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided December 4, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include FANCC gene 
testing are not covered. 
 
We looked at the file and Medicare rules. This panel included the FANCC gene and is non-covered. Based on 
this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided December 4, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic 
service (99053) provided on August 19, 2021. 
 
You asked the Plan to pay for services provided at 24-hour facility, in addition to basic service (99053). The 
Plan denied your request. The Plan says procedure code 99285 was paid, and procedure code 99053 remains 
denied as bundled services are not eligible for separate payment. 
  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 code 99053 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99053 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of services provided at 24-hour facility, in addition to basic service (99053) have not been met. Therefore, we 
decided that the Plan does not have to pay for services provided at 24-hour facility, in addition to basic service 
(99053) provided on August 19, 2021.
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 you need rehab services to assist with motor function 
after your neck surgery. The Plan denied your request. The Plan says IRF care is not medically necessary and 
your needs can be met in an alternate setting such as in a skilled nursing facility, at home with home health 
services or with outpatient therapy. 
 
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 while you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program such as an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87150) provided on March 9, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not 
support this code. 
 
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 87150 is "Culture, typing; identification by nucleic acid 
(DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed". 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 87150 is 
not supported by the records provided. Our reviewer found that the medical record does not include 
documentation of "culture, typing; identification by nucleic acid probe, amplified probe technique, per culture 
or isolate", and therefore this code cannot be verified. 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (87150) provided on March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for supply allowance used with a therapeutic CGM device (K0553) 
provided September 27, 2021. 
 
You asked the Plan to pay for the CGM device supplies. You say that kindly find all the attached records and 
reprocess the claim. The Plan denied your request. The Plan says that the records do not support the billed 
service. 
 
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM device supplies. Our reviewer says 
that the requested items/services is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has type 2 diabetes and neuropathy and checks glucose 3 or more times daily with 
her CGM or glucometer. She is treated with Levemir once at bedtime and Novolog at each meal (3-4 
times/day) and also takes Metformin and requires daily adjustments in treatment based on readings. Refill 
supplies for her therapeutic CGM device was requested and appear to be supported by the provided 
documentation. 
 
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 CGM device supplies have been met. Therefore, we decided that the Plan 
has to pay for supply allowance used with a therapeutic CGM device (K0553) provided September 27, 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 Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says reasonable goals have been reached for daily tasks. 
 
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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment at this time. Your pain level is stable. You 
have had minimal improvements in terms of single leg stance, and motor strength. Your Oswestry low back 
scores remain stable. You can continue with an independent exercise program, and the skilled services of a 
physical therapist are not needed to perform this. The requested physical therapy is not part of a maintenance 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
December 27, 2021. 
 
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
 
 
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the subsequent nursing facility care services provided on December 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says there is no contraindication or intolerance to the 
preferred agent. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Evenity. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the Plan requires a trial of Forteo before 
they will approve the requested drug, Evenity. Based on the medical records provided there is no indication that 
the enrollee has tried and failed the required drug. There is no indication that the Plan's required drug would 
likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 30, 
2021, to March 31, 2021. 
 
You asked the Plan to pay for SNF care. You say that this was billed correctly. The Plan denied your request. 
The Plan says this was not billed with a valid Patient Driven Payment Model (PDPM) code. 
 
The Plan must follow Medicare rules. Medicare rules say that when a claim is being paid under the SNF 
Prospective Payment System (PPS), revenue code 0022 must be reported with a 5-digit Health Insurance 
Prospective Payment System (HIPPS). 
 
We looked at the file and Medicare rules. The claim for the services at issue was not billed with a 5-digit 
HIPPS code. 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 pay for skilled nursing facility (SNF) care 
provided from March 30, 2021, to March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth service, provided on January 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says telehealth services must be obtained in-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 pay for care for telehealth services when obtained from a network provider. 
 
 
 
 
 
 
 
 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 telehealth service, provided on January 26, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on December 8, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the item is medically necessary. The Plan denied 
your request. The Plan says a valid proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Neither the date on the packing slip or delivery slip 
matched the date of service. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies (K0553), provided on December 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam (92014) provided January 25, 
2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was a screening service and 
should be covered. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 a $25 
copayment for non-routine eye exams.  
 
 
 
 
 
 
 You have been asked to pay a $25 copayment for the eye exam. The eye exam falls within the non-routine eye 
exams 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 an eye exam (92014) provided 
January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on November 26, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items were medically necessary. The Plan 
denied your request. The Plan says a valid proof of delivery was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. Neither the date on the packing slip or delivery slip 
matches the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous 
glucose monitor (CGM) supplies (K0553), provided on November 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on February 10, 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 that this code is not eligible for payment. 
 
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 00811 is "Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to 
duodenum; not otherwise specified." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the anesthesia services were provided 
by an anesthesia provider/certified registered nurse assistant (CRNA). The CPT code billed for the anesthesia 
services provided was appropriate.  The records indicate that this provider specialty (CRNA) may bill for the 
anesthesia services rendered for the procedure on 2/25/2022. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
anesthesia services provided to the enrollee on February 10, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins including responses to 
compression and other maneuvers; complete bilateral study provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for duplex scan of extremity veins including responses to compression and other 
maneuvers; complete bilateral study. You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the member's plan excludes coverage for this out-of-network 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 duplex scan of extremity veins including 
responses to compression and other maneuvers; complete bilateral study provided on January 26, 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 office visit and chiropractic manipulative treatment 
provided by an out-of-network provider from October 5, 2021, to November 23, 2021. 
 
You asked the Plan to pay for an office visit and chiropractic manipulative treatment. You say that you would 
like these services covered. The Plan denied your request. The Plan says the services were provided out-of-
network and an in-network provider was available. 
 
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 office visit and chiropractic manipulative 
treatment provided by an out-of-network provider from October 5, 2021, to November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmology services (92083, 92133, 92014, 92012) 
provided March 24, 2021 to December 15, 2021. 
 
You asked the Plan to pay for the ophthalmology services. You say that these services should be covered. The 
Plan denied your request. The Plan says the deductible was not met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to covered medical services.  
 
 
 
 
 
 
 
 
 
 
 The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to covered medical services. This cost sharing is a contractual obligation that had not been met at the 
time the ophthalmology services was received on March 24, 2021 to December 15, 2021. Therefore, we 
decided that the Plan does not have to pay for ophthalmology services (92083, 92133, 92014, 92012) provided 
March 24, 2021 to December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing provided on January 26, 2022, 
billed with code 80307. 
 
You asked the Plan to pay for the presumptive drug testing. You say that this testing was medically necessary 
as ordered by the treating physician. The Plan denied your request. The Plan says presumptive testing was 
billed and paid to the physician on this date of service. Only one presumptive test can be paid. 
 
The Plan must follow Medicare rules. Medicare will only pay for one presumptive test result per patient per 
date of service regardless of the number of billing providers.   
 
We looked at the file and Medicare rules. The file shows that payment was made for a presumptive drug test 
done by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the 
presumptive drug testing have not been met.  
 
  
Therefore, we decided that the Plan does not have to pay for the presumptive drug testing provided on January 
26, 2022, billed with code 80307.