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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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. 
 
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 reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found as of the last covered day, you did not require any skilled nursing or rehabilitation 
services on a daily basis. You did not require skilled therapy to establish a safe and effective maintenance 
program. As a practical matter, you did not require any skilled services on an inpatient basis, at a skilled level 
of care as of November 5, 2022. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service May 18, 
2022. 
 
You asked the Plan to pay for procedure code 86077. You say that the services at issue were billed correctly. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on June 24, 
2022, to June 27, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for inpatient hospital services.  
 
You have been asked to pay a $300 copayment for inpatient hospital services. This item/service falls within the 
Inpatient hospital care 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 inpatient 
hospital services on June 24, 2022, to June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 6, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this testing has been determined to be medically 
reasonable and necessary. The Plan denied your request. The Plan says FANCC testing is statutorily excluded 
from coverage, and Medicare will also deny panels of tests that include the FANCC gene. 
 
The Plan must follow Medicare rules. Medicare rules say that panel tests including the FANCC gene are not 
covered.  
 
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. Therefore, we decided that the Plan does not have to pay for 
genetic testing provided on May 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pharmacogenomic testing billed with codes 81226, 81227, 
81230, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 
81407, 81406, and 81238 provided on March 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says there is not enough 
medical documentation to show what drugs the doctor wants to use and how results will impact treatment. 
 
The Plan follows Medicare rules. Medicare rules say that the testing will be covered if the patient has a 
condition that needs a medication that has a known gene-drug interaction(s) for which the test results would 
directly impact the drug management of the patients condition. 
 
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 testing. Our reviewer says that the service is not medically necessary. Our physician reviewer found the record indicates that the 
enrollee underwent comprehensive hereditary pharmacogenomic testing and hereditary genetic cardiac testing.  
The record provided is insufficient to establish that the patient has a condition where clinical evaluation has 
determined the need for a medication that has a known gene-drug interaction(s) for which the test results would 
directly impact the drug management of the patients condition. The record is insufficient to establish how the 
results would specifically impact the enrollee's clinical management. 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.  
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for pharmacogenomic testing billed with codes 81226, 81227, 81230, 81231, 81232, 81240, 81241, 
81291, 81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81407, 81406, and 81238 provided on 
March 21, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits, 3 home health 
physical therapy visits, 3 home health aide visits, 1 home health occupational therapy visit, 1 speech-language 
pathologist visit, 1 clinical social worker visit to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home health care services to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The provider at issue in this case is not a network provider with the Plan. 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 home health care services. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found the enrollee is not shown to have an emergent or urgent condition. The enrollee is seeking care for chronic knee pain. There is no evidence that the requested services 
are not available in-network. As such, the use of an OON provider is not shown to be medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care services have not been met.  
 
The Plan has network providers available who can provide the items/services at issue in this appeal. We found 
no exception that would require the Plan to pre-approve home health care services. Therefore, we decided that 
the Plan does not have to pre-approve 3 home health skilled nursing visits, 3 home health physical therapy 
visits, 3 home health aide visits, 1 home health occupational therapy visit, 1 speech-language pathologist visit, 
1 clinical social worker visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on June 22, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing determines if there was a more 
effective therapy to treat the enrollee. The Plan denied your request. The Plan says there is a more appropriate 
code to describe the services provided. 
 
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 the panel testing was not billed with a single code 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 gene panel testing provided on June 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on June 6, 2022, and June 
7, 2022. 
 
You asked the Plan to pay for the drugs. You say that Medicare should cover the medications given in the 
hospital at the 100% level. The Plan denied your request. The Plan says this was billed as A9270 for a non-
covered item or service. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on June 6, 2022, and June 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation services. 
 
You asked the Plan to pre-approve additional mileage for routine transportation services. You say that you 
would like this claim reprocessed as it is necessary for you to receive additional mileage to reach your 
destination. The Plan denied your request. The Plan says the benefit limit is exhausted at 50 miles of driving 
distance. 
 
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 routine transportation trips when the distance is to not exceed 50 miles of one-way 
driving distance. We looked at your request, the records in the case file, and the rules. In this case, the destination in question is 
to exceed 50 miles of driving distance. Therefore, we decided that the Plan does not have to pre-approve 
additional mileage for routine transportation services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 home health physical therapy visits. 
 
You asked the Plan to pre-approve 9 home health physical therapy visits. 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. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 9 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
does not have documented skilled therapy needs. The enrollee was doing well at the time of evaluation and has 
progressed with the few visits provided since then. The enrollee is functioning at a level commiserate with a 
lower level of care. As such, the requested number of home health physical therapy visits is not shown to be 
medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 9 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 10, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 is a column II code to column I code 70496. 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 procedure code 70450 
billed for date of service July 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for progressive lenses (V2781) and antireflective coating 
(V2750), provided on June 28, 2022. We also decided that the Plan does not have to pay more for frames 
(V2020), and polycarbonate lenses (V2784) also provided on June 28, 2022. 
 
You asked the Plan to pay for progressive lenses (V2781), and antireflective coating (V2750). You also asked 
the Plan to pay more for frames (V2020), and polycarbonate lenses (V2784). You say that you were told that 
you would need to pay for the glasses up front and then be reimbursed for the cost. You also say that you are 
supposed to receive free glasses after cataract surgery. The Plan denied your request. The Plan says the claim 
processed correctly according to the benefits in the EOC. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers frames (V2020) and polycarbonate lenses (V2784) when they are provided by an in-
network provider. When received from an out-of-network provider there is a 20% coinsurance for frames 
(V2020) and polycarbonate lenses (V2784). Progressive lenses (V2781) and antireflective coating (V2750) are 
excluded from this benefit. 
 
We looked at the file and the Plan's rules. You have been asked to pay 20% coinsurance for the frames (V2020) 
and polycarbonate lenses (V2784). The Plan contract also says that Progressive lenses (V2781) and 
antireflective coating (V2750) are excluded from this benefit. Based on this information, we decided that the 
Plan's rules for coverage of frames (V2020), progressive lenses (V2781), antireflective coating (V2750), and 
polycarbonate lenses (V2784) have not been met. Therefore, we decided that the Plan does not have to pay for 
progressive lenses (V2781) and antireflective coating (V2750), provided on June 28, 2022. We also decided 
that the Plan does not have to pay more for frames (V2020), and polycarbonate lenses (V2784) also provided 
on June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for the continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve a backup battery. You say that this is necessary due to frequent power 
outages. The Plan denied your request. The Plan says backup medical equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a CPAP machine. The requested backup battery serves the same purpose as the 
primary power supply for the CPAP machine. Therefore, we decided that the Plan does not have to pre-approve 
a backup battery for the continuous positive airway pressure (CPAP) device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you are disputing the share cost. The 
Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $200 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $200 copayment for CT scan. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for CT scan provided on June 28, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve transforaminal epidural steroid injections (TFESIs) (64483, 
64484). 
 
You asked the Plan to pre-approve the injections. You say that the enrollee tried 6 weeks of physical therapy in 
2019. You say that it was not beneficial. You say that the enrollee is currently participating in a home exercise 
program. You also say that the enrollee has also tried NSAIDs. The Plan denied your request. The Plan says 
that the requested injections are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements 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 the injections. Our reviewer says that 
the requested TFESIs are medically necessary. Our physician reviewer found the provided documentation 
indicates the enrollee has chronic low back pain with radiculopathy. The reviewer found that the 
documentation indicates the enrollee failed conservative therapy. Therefore, the reviewer found that the 
requested TFESIs are medically reasonable and 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 injections have been met. Therefore, we decided that the Plan has to pre-
approve transforaminal epidural steroid injections (TFESIs) (64483, 64484).  
 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this was not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 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 76770 is a column II code to column I code 93976. 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 procedure code 76770 
billed for date of service June 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a cardiac loop monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover services that are not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We 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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias noted on 
electrocardiogram monitoring. A recent randomized clinical trial found that continuous monitoring for atrial 
fibrillation with an ILR (followed by treatment with oral anticoagulation if atrial fibrillation was detected) was 
not superior to usual care in reducing stroke or systemic embolism among patients at high risk of stroke but 
without a known prior history of atrial fibrillation. At this time, insertion of an ILR would not be considered 
medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a cardiac loop monitor.