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

 
We decided that the Plan does not have to pay for the laboratory services (81291 GZ) provided on November 
11, 2021. 
 
You asked the Plan to pay for code 81291 GZ. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that items and services 
that are not medically necessary are not covered. Medicare rules state that items submitted with a GZ modifier 
shall be denied automatically and will not be subject to complex medical review.  
 
We find that CPT code 81291 is not supported in the medical record. Specifically, this service includes the GZ 
modifier, which by definition means that these services do not meet the criteria for Medicare coverage. 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 the laboratory services (81291 GZ) provided on 
November 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 8, 2021, to 
August 13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient admission was medically 
necessary The Plan denied your request. The Plan says that these services could have been provided under 
observation care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has a past medical history of end stage renal disease on hemodialysis, 
hypertension, diabetes, congestive heart failure and anemia. She had had four outpatient transfusions of packed 
red blood cells in the month prior to presenting for evaluation of shortness of breath and anemia. Hemoglobin 
was 7.3 and creatinine was 5.7 at the time of admission on 8/8/21. Treatment plan included consultation with 
nephology and hematology/oncology, transfusion of packed red blood cells, and a bone marrow biopsy. Eliquis 
was to be held prior to bone marrow biopsy. She was discharged on 8/13/21. The record does show that at the 
time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier ED and/or observation care) would span two midnights and the provision of medically 
necessary care did span a time period of greater than two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 8, 2021, to August 13, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 10, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says this testing was not billed correctly with a single panel code. 
 
The Plan must follow Medicare rules. Medicare 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 testing is 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 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic testing supplies provided from November 16, 
2021, through February 13, 2022. 
 
You asked the Plan to pay for the diabetic testing supplies. You say that the records support the services 
provided were medically necessary. The Plan denied your request. The Plan says no proof of delivery was 
included with the appeal. 
 
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 for the supplies provided in this case. Though a packing slip was included, it was not signed by the enrollee confirm receipt, nor was a delivery confirmation from a 
shipper included. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies 
provided from November 16, 2021, through February 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for infectious agent antigen detection by immunoassay 
technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence 
immunoassay [FIA], immunoch (CPT code 87426), non-covered item or service (CPT code A9270), and sales 
tax (CPT code S9999) purchased on January 28, 2022. 
 
You asked the Plan to reimburse for the services. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says the services are not covered.  
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met.  
 
Medicare will not provide payment for over-the-counter COVID-19 tests obtained prior to April 4, 2022. 
Starting April 4, 2022, there is a Medicare initiative that will cover up to eight (8) over-the-counter COVID-19 
tests each calendar month. Medicare cannot process a claim submitted by a beneficiary for a COVID-19 over-
the-counter test. The beneficiary should check whether their pharmacy or health care provider is participating 
in the initiative, in which case they will bill Medicare for the over-the-counter test on your behalf. It was also 
determined that the 2022 National Physician Fee Schedule lists code A9270 with a status indicator of N, 
which indicates that this is a non-covered service. After review, it was determined that Medicare does not 
reimburse separately for sales tax. Therefore, we decided that the Plan does not have to reimburse for infectious 
agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked 
immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunoch (CPT code 87426), non-covered 
item or service (CPT code A9270), and sales tax (CPT code S9999) purchased on January 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from July 24, 2021, through 
August 18, 2021. 
 
You asked the Plan to pay for home health services. You say that the initial code calculated correctly and there 
is not a lack of documentation to support the code. You say that the pressure ulcer is documented, and the 
claim should be reconsidered. The Plan denied your request. The Plan says the provider has not submitted any 
clinical records to support the medical necessity of the services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health services provided from 
July 24, 2021, through August 18, 2021. have been met. Specifically, medical records were not submitted to 
determine if criteria for coverage of home health services have been met. Therefore, we decided that the Plan 
does not have to pay for home health services provided from July 24, 2021, through August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy, breast, with placement of breast localization 
device(s) (19085) provided on November 17, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the breast biopsy. You say that documentation has been attached for review. 
Upon review you ask for reprocessing of the denied charges. 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 the biopsy, breast, with placement of breast 
localization device(s) (19085) provided on November 17, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from March 1, 2022, 
to March 3, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that this could have been provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee presented on 3/1/22 with mental status changes and hallucinations. Evaluation in 
the Emergency Department noted blood pressure 139/88, pulse 70, respirations 4, temperature 98.3, and pulse 
ox 88%. Examination revealed altered mental status with no other focal findings. Urinalysis showed 3 + 
leukocytes and 3 + blood. He was admitted for acute metabolic encephalopathy and acute cystitis. Treatment 
included intravenous fluids, intravenous antibiotics and a bedside sitter for safety. After the first midnight's 
time of care, he remains confused compared to his baseline and still required a bedside sitter for safety. The 
record shows that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee from March 1, 2022, to March 3, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 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 Prolia. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 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 admission to a SNF. Our reviewer says 
that the enrollee does not meet criteria for SNF admission. Our physician reviewer found the enrollee is status 
post vertebral fracture and fusion. From a nursing perspective, the enrollee received oral medications. The 
enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech 
therapy, and occupational therapy. The enrollee was at a supervision/stand by assist level for functional 
mobility including gait to 350 feet with a rolling walker. The enrollee required varying assist with activities of 
daily living. He had ongoing cognitive linguistic deficits. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips when each one-way trip does not exceed 
75 miles. 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation mileage.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollees care needs can be met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing provided on September 21, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for lab testing. You say that you were unaware that prior authorization was needed. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab testing provided on September 21, 2021, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on December 28, 
2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with melanoma. The FDA 
approval notice indicates that this panel is approved for melanoma. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on December 28, 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.