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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that it is not safe to be discharged home at this point. 
The Plan denied your request. The Plan says the guidelines for coverage of continued SNF care have 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 services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, received a course of IV antibiotics, had clear lungs, and continued dialysis. 
The enrollee received physical therapy and occupation therapy. The enrollee was at a modified independent 
level of functional mobility, including gait to 100 feet. The enrollee required varying assist with activities of 
daily living. There are no further identifiable skilled nursing or skilled therapy service needs. The enrollee does 
not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded with 81286 and 81479 provided October 18, 2021.

You asked the Plan to pay for the laboratory services. You say that you believe the treatment sought is medically necessary to treat the enrollee based on the enrollee's medical condition. The Plan denied your request. The Plan says services do not meet coverage requirements.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening as outlined by 42 CFR 410.17. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing coded with 81286 and 81479 provided October 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on November 9, 
2020. 
 
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 the records do not support payment for the services 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. 
 
In this case, the CPT Code Manual definition of code 93456 is "Catheter placement in coronary artery(s) for 
coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision 
and interpretation; with right heart catheterization." 
 
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 not supported by the medical records. Our reviewer found that the procedure report does not 
include documentation of a catheter placed into a blood vessel. In this case, the procedure 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 surgical services provided to the enrollee on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the osseous surgery (including elevation of a full 
thickness flap and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), bone 
replacement graft  retained natural tooth  first site in quadrant (D4263), biologic materials to aid in soft and 
osseous tissue regeneration, per site (D4265), and guided tissue regeneration - resorbable barrier, per site 
(D4266). 
 
You asked the Plan to pre-approve the osseous surgery, bone replacement graft, biologic materials and guided 
tissue regeneration. You say that you would like these services covered. The Plan denied your request. The 
Plan says these services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261), bone replacement graft  retained natural tooth  first site in 
quadrant (D4263), biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and 
guided tissue regeneration - resorbable barrier, per site (D4266).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia services coded 99100 and 99135 
provided on August 17, 2021. You asked the Plan to pay for the special anesthesia services as billed. You say 
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The 
Plan says no separate payment is made for these services per Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99100 and 99135 each have status indicators of B on the Physician Fee Schedule. This 
means that CPT codes 99100 and 99135 are not separately payable. Based on this information, we decided that 
Medicare rules for coverage of the special anesthesia services as billed have not been met. Therefore, we 
decided that the Plan does not have to pay for the special anesthesia services coded 99100 and 99135 provided 
on August 17, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on August 21, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the service 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. In this case, the CPT Code Manual definition of 
code G0483d is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual 
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited 
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., 
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the lab report clearly shows that 
22+ drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing provided on August 21, 2018.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided to the enrollee on January 
14, 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 the plan policy covers non-emergency ambulance transportation when it is the only way to safely 
and adequately transport an enrollee, or if other means of transporting are unsafe due to a medical condition. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for this patient. The record cites inability to sit for 
transport but does not indicate why a stretcher van would not have been an appropriate means of 
transports. The documentation does not support that the patient needed the expertise, services and lifesaving 
and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The 
transport was from hospital to a residence and the patient was noted to be in stable condition. There was no 
documentation of need for BLS or ALS monitoring or intervention. The documentation does not support that the ambulance transport was medically reasonable and necessary for the patient on 1/14/22. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for ambulance transportation provided to the enrollee on January 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 7, 2022, through 
April 8, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the care provided from April 7, 2021, through April 8, 2021, was not 
medically necessary. 
 
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 patient was admitted on January 8, 2021, for COVID-19 infection and was treated for 
respiratory failure, sepsis, atrial fibrillation, and acute renal failure. He had percutaneous endoscopic 
gastrostomy (PEG) placed, tracheostomy, and required dialysis during his hospital stay. He was discharged on 
April 8, 2021. 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 medically necessary care did span more than two midnights. The requested care continued 
to be medically necessary throughout the length of the enrollee's stay. 
 
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 April 7, 2022, through April 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on July 23, 2018. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the services 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. In this case, the CPT Code Manual definition of 
code G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0482 is supported in the medical record. Specifically, the lab report clearly shows that 
15-21 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Additionally, the Plan has not forwarded any evidence to support why CPT code 
80307 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. 
In this case, the Plan's denial has not been substantiated so we must find in your favor. Also, the record 
indicates that this provider was directed by the Plan to not obtain records. With this direction, it is inappropriate 
for the Plan to deny these services based on the physician signature. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have been met. Therefore, we decided that the Plan has to pay 
for drug testing provided on July 23, 2018.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee from May 11, 2021, 
to May 13, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the admission and stay was medically 
necessary. The Plan denied your request. The Plan says that this could have been an observation stay. 
 
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 that 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 medically necessary care did span more 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 inpatient hospital services provided to the enrollee from May 11, 2021, to May 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 November 14, 2021, billed 
with codes 81201, 81404, 81405, and 81406. 
 
You asked the Plan to pay for this genetic testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says this must be billed with a single code. Therefore, the Plan only agreed to 
pay for 3 line items.  
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 panel is NGS testing that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of this genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 14, 2021, billed with codes 81201, 81404, 81405, and 81406.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits. 
 You asked the Plan to pre-approve additional home health services. You say that additional home health skilled 
nursing services are medically necessary. The Plan denied your request. The Plan says there is no medical need 
for the additional home health services beyond what has already been approved. 
 
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 additional home health services. Our 
reviewer says that the requested additional home health services are not medically reasonable and necessary. 
Our physician reviewer found that, based on the documentation provided, the enrollee does not have 
documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing services are 
not 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 additional home health services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 5 additional home health skilled nursing visits.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional trips for routine transportation beyond the Plan's 
24-trip limit. 
 
You asked the Plan to pay for additional trips for routine transportation. You say that the enrollee needs 
transportation to dialysis. The Plan denied your request. The Plan says additional trips are not covered. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The requested services exceed your 24-trip limit. 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 pay for additional trips 
for routine transportation beyond the Plan's 24-trip limit.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81206, 81235, 81292, 81301, 81321) 
performed August 31, 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 the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a genetic testing panel constitutes a single 
procedural service, so one code must be submitted for the panel. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. 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 (81206, 81235, 81292, 81301, 
81321) performed August 31, 2021.