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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 15, 2022, to March 16, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says no skilled services were provided, rehabilitative or nursing. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found that at 
the time of admission, the enrollee required skilled rehab services to improve function due to weakness and 
deconditioning. There were no skilled nursing needs upon admission. As of 2/14/22, the enrollee no longer 
required any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or ADLs. The enrollee did not require skilled therapy establish a safe and effective maintenance 
program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care as of 2/14/22. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from February 15, 2022, to 
March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunofixation electrophoresis (86334) provided on 
February 7, 2022. 
 
You asked the Plan to pay for immunofixation electrophoresis. You say that this was medically necessary. The 
Plan denied your request. The Plan says this was not billed with a required modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that it is mandatory to report a clinical trial number 
on claims for items/services provided in clinical trials/studies/registries, or under coverage with evidence 
development CED. In addition to the clinical trial number, claims shall include diagnosis code Z00.6 and 
modifier Q0 or Q1 as appropriate.  
 
We looked at the file and Medicare rules. The service at issue was billed with diagnosis Z00.6 to indicate it was 
provided for a clinical study, but modifier Q0 or Q1 was not included. Based on this information, we decided 
that Medicare rules for coverage of immunofixation electrophoresis have not been met. Therefore, we decided 
that the Plan does not have to pay for immunofixation electrophoresis (86334) provided on February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy pump. 
 
You asked the Plan to pre-approve a negative pressure wound therapy pump. You say that this equipment is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been 
satisfied. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a negative pressure wound therapy 
pump have been met. In this case, the medical records that were received are over a year old. In order to assess 
whether the criteria for coverage for the negative pressure wound therapy pump have been satisfied, it is 
expected that current medical records would be provided. Without current medical records, it is impossible to 
ascertain whether coverage criteria have been satisfied. Therefore, we decided that the Plan does not have to 
pre-approve a negative pressure wound therapy pump.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical-necessity rules for coverage of 
the requested service have not been met. 
 The Plan follows Medicare rules. The rules say that ESI will be considered medically reasonable and necessary 
when the criteria listed in the Medicare rules section have been 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 an epidural steroid injection. Our 
reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician 
reviewer found that there is a lack of documentation of the effectiveness of prior injections and the duration of 
the pain relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Imfinzi (J9173). 
 
You asked the Plan to pre-approve Imfinzi. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says medical-necessity rules for coverage have not been met 
because the requested drug has been prescribed for an off-label and not medically supported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Imfinzi. Our reviewer says that the 
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the 
use of Imfinzi in this setting for stage III non-small cell lung cancer without prior platinum-based 
chemotherapy is not FDA-approved. Additionally, this use of Imfinzi is not supported by one of the major drug 
compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Imfinzi (J9173).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 11, 2021, billed 
with codes 81161, 81252, 81256, 81286, 81400, 81410, 81411, 81413 and 81414. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical record. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules, as a comprehensive panel is being billed with stacking codes. 
 
The Plan must follow Medicare rules. The 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 was 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 billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
November 11, 2021, billed with codes 81161, 81252, 81256, 81286, 81400, 81410, 81411, 81413 and 81414.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes S1015, S8301, A4649, and A4550, billed 
for date of service September 22, 2021. 
 
You asked the Plan to pay for the billed codes. The Plan denied your request. The Plan says these services 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 procedure code. 
 
We find that procedure codes S1015 and S8301 have a Status Indicator of I on the Physician Fee Schedule. 
This means that procedure codes S1015 and S8301 are not valid for Medicare purposes. We also find that code 
A4550 has a status indicator of B on the Physician Fee Schedule. This means that code A4550 is not separately 
payable. We also find that code A4649 has as a Status Indicator of P on the Physician Fee Schedule. This 
means that this is a bundled/excluded code and separate payment cannot be made. Based on this information, 
we decided that Medicare rules for coverage of the billed codes have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure codes S1015, S8301, A4649, and A4550, billed for date of service 
September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic care provided from March 29, 2022, to April 11, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic care. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 chiropractic care provided from March 29, 2022, 
to April 11, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve TTE. 
 
You asked the Plan to pre-approve TTE. You say that TTE is medically necessary. The Plan denied your 
request. The Plan says TTE does not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve TTE. Our reviewer says that TTE is not 
medically necessary. Our physician reviewer found that the documentation would not point to a change in 
status that would support the medical necessity of a repeat TTE at this time. Clinical guidelines do not support 
repeating a TTE without intervening change in clinical status or new signs, symptoms or physical findings. In summary, there is no supportive evidence for the medical necessity of repeat TTE in this enrollees 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 TTE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve TTE.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 9, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you believe the provider did not verify 
coverage with plan. The Plan denied your request. The Plan says the services were provided out-of-network 
and were not approved in advanced. 
 
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 laboratory services provided on February 9, 2022, 
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on February 7, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say that your provider is in-network 
with the Plan. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized. 
 
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 a psychiatric diagnostic evaluation provided on 
February 7, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (K0800). 
 
You asked the Plan to pre-approve a power scooter. You say that you are requesting the power scooter so that 
you can travel longer distances in your community. The Plan denied your request. The Plan says the scooter 
must be used mostly for activity within your home. The requested power scooter does not meet Medicare 
criteria. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (K0800).
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 enrollee needs SNF care. The Plan denied your 
request. The Plan says the enrollee does not meet criteria for skilled services. 
 
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 that 
SNF care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not 
have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that published studies do not demonstrate any long-term health 
outcome advantage with the use of Intracept as an alternative to standard surgical treatment. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There are multiple 
plausible pathologic sources of significant pain generation. Overall, documentation is lacking regarding 
reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the 
overwhelming primary generators of the enrollees chronic persistent pain. Our physician reviewer found that 
the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with 
written report (85060) billed for date of service, March 21, 2022. 
 
You asked the Plan to pay for code 85060. You say that these services were ordered by a contracted physician 
and were medically necessary. The Plan denied your request. The Plan says code 85060 was billed incorrectly 
in this case. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules say that code 85060 is used only when a physician interprets an abnormal peripheral blood smear for a hospital inpatient or a hospital outpatient, and 
the hospital is responsible for the technical component. When an independent laboratory bills a physician 
interpretation of an abnormal peripheral blood smear, the service is considered a complete or global service, 
and is not billed under the CPT code 85060. 
 
We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed by an 
independent laboratory. However, based on Medicare rules, if an independent laboratory bills a physician 
interpretation of an abnormal peripheral blood smear, the service is not billed under CPT code 85060. Based on 
this information, we decided that Medicare rules for coverage of code 85060 have not been met. Therefore, we 
decided that the Plan does not have to pay for blood smear, peripheral, interpretation by physician with written 
report (85060) billed for date of service, March 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination of the chest provided on  
April 20, 2020. 
 
You asked the Plan to pay for radiologic examination of the chest. The Plan denied your request. The Plan says 
a corrected claim must be receive within one year (12 months) from the processed date of the original claim. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for radiologic examination of the chest was not filed until March 29, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for radiologic examination of the chest provided on 
April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Covid-19 testing provided on February 18, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing should be covered with no cost 
share. The Plan denied your request. The Plan says the testing is not a covered benefit. 
 
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. 
 
 We looked at the file and the rules. The records do not show that you were directly exposed to or were 
experiencing any signs or symptoms related to the coronavirus. Medicare does not cover this test solely for 
screening purposes. Therefore, we decided that the Plan does not have to pay for the Covid-19 testing provided 
on February 18, 2022.