Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine skilled nursing visits. 
 
You asked the Plan to pre-approve nine skilled nursing visits. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
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 nine skilled nursing visits. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has a lower extremity wound, for which she is receiving wound care 
from a wound clinic, a home health skilled nurse and the enrollee's son. While the wound care is necessary, it is 
unclear why more frequent home health skilled nursing visits are required to provide the necessary care. 
Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nine skilled nursing visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve nine skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the acute inpatient hospital care provided from October 24, 2021, 
forward. 
 
You asked the Plan to pre-approve the acute inpatient hospital care provided from October 24, 2021, forward. 
You say that the services are medically necessary. The Plan denied your request. The Plan says that the 
documentation does not support medical necessity. 
 
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 pre-approve the acute inpatient hospital care 
provided from October 24, 2021, forward. Our reviewer says that the documentation supports that the criteria 
for inpatient payment are met in this case. Our physician reviewer found that the enrollee had worsening 
shortness of breath, labored breathing upon exertion and a weight gain of 6 pounds in 3 days. She was admitted 
and received continuous intravenous infusion and was managed for Hypoxemic Respiratory Failure. A left 
ventricular assist device was placed. The record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department 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 the acute inpatient hospital care provided from October 24, 2021, forward have 
been met. Therefore, we decided that the Plan has to pre-approve the acute inpatient hospital care provided 
from October 24, 2021, forward.  
 
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 the services (70450) provided on June 22, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 the services (70450) provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme comprehensive genomic profiling 
test provided on April 27, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the F1 Heme test is a proven medically necessary covered benefit for comprehensive genomic 
profile (CGP) testing for cancer to identify potential targeted therapy options in beneficiaries with a diagnosis 
of Acute Myeloid Leukemia (AML), Myelodysplastic Syndromes (MOS), Myelodysplastic 
Syndromes/Myeloproliferative Neoplasms (MDS/MPN), and Myeloproliferative Neoplasms (MPN). In this 
case, the enrollee has a diagnosis of non-Hodgkins lymphoma. 
 
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 the FoundationOne Heme comprehensive genomic profiling test provided on April 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on June 23, 2021. 
 
You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
The medical records show that you received an EGD at an outpatient hospital facility on June 23, 2021. An 
EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount 
of $176.95, which is less than the $250 copayment.   
 
You have been asked to pay the copayment amount of $176.95 for an EGD. An EGD falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 
24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 24, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
care in an LTACH. The Plan denied your request. The Plan says the criteria for coverage of LTACH care have 
not been met. The Plan says that the enrollee is receiving appropriate inpatient acute care and does not require 
transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 19, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician's intent that the tests be performed. 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 
drug testing services (G0483) provided on May 19, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary oxygen tank for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is being requested for preventive or precautionary purposes. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 the 
requested services are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has sleep apnea. The records provided are insufficient to establish that the criteria are 
satisfied. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stationary oxygen tank for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection 
control supplies coded S8301 provided on April 28, 2021. 
 
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
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 S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment of these services. Based on this information, we 
decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have 
not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded 
S1015 and the infection control supplies coded S8301 provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received on June 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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 received on June 22, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical x-rays (D0220), 
endodontic therapy, molar tooth (D3330), and sales tax (D9985) provided by an out-of-network provider on 
June 1, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, periapical x-rays, endodontic therapy, molar tooth, and 
sales tax. You say that this should all be included in the root canal. The Plan denied your request. The Plan says 
the claim has been correctly processed. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a limited oral 
evaluation, periapical x-rays, endodontic therapy, molar tooth when provided by a participating provider. Sales 
tax is not a covered benefit. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a limited oral evaluation, periapical x-rays, endodontic therapy, molar tooth, and sales tax have not 
been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), 
periapical x-rays (D0220), endodontic therapy, molar tooth (D3330), and sales tax (D9985) provided by an out-
of-network provider on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 27, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the services were provided in good faith. The 
Plan denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the testing services at issue in this appeal. The Plan did not pre-approve the services 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the drug testing services provided on May 27, 2021, by an out-of-network 
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 9, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not covered 
for screening. 
 
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99203) provided on June 9, 
2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 an in-network specialist visit.  
 
You have been asked to pay a $25 copayment for the in-network specialist visit provided. 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 the office visit (99203) provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services (97032, 97016), drug and administration 
services (96372, J3490, J3415, J3411), and evaluation and management services (99212) provided on 
December 28, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed and 
approved for payment. The Plan denied your request. The Plan says experimental and/or investigational 
services are not covered. 
 
Therapy services (97032, 97016) 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical 
therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private 
practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that 
NP/PA may perform physical therapy services under State law. 
 
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Arizona. 
 
Drug and administration services (96372, J3490, J3415, J3411) 
 
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted 
using a compounded drug, not otherwise classified (NOC) code. 
 
The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The 
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, 
the drug administration code, 96372, also cannot be paid. 
 
Evaluation and management services (99212) 
 
The Plan must follow Medicare rules. Medicare rules say that Modifier 25 is defined as a significant, separately 
identifiable Evaluation and Management (EM) service by the same physician or other qualified health care 
professional on the same day of a procedure or other service.  
 
The office visit at issue was billed with modifier 25, which is used to report a significant, separately 
identifiable Evaluation and Management (EM) service by the same physician or other qualified health care 
professional on the same day of a procedure or other service. There is no documentation of any significant, 
separately identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for the therapy services (97032, 97016), drug and administration services (96372, J3490, J3415, J3411), and 
evaluation and management services (99212) provided on December 28, 2020.