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

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on December 21, 
2021. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on December 21, 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: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit (99285) provided September 28, 2021. 
 
You asked the Plan to pay for the emergency visit. You say that the enrollee was originally seen in your ER, 
however after initial evaluation, the enrollee had to be admitted for further treatment. Please review the 
enclosed medical records and reprocess the claim for payment. The Plan denied your request. The Plan says 
that this is a duplicate claim that has already been considered for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. the plan has not provided a valid reason for their reason to continue to deny. The 
record show the Plan initially denied that the provider did not meet provider requirements. The Plan has not 
provided a valid reason why the provider is not a valid provider. The Plan has also not provided any 
documentation that shows the services had been paid. The Plan has not substantiated their reason to continue to 
deny payment. Therefore, we decided that the Plan has to pay for the emergency department visit (99285) 
provided September 28, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 5, 
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 they did not authorize any services for this provider. 
 
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 to the enrollee on 
January 5, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 16, 
2021. 
 
You asked the Plan to pay for the SNF services. You say that this enrollee resides in a long-term care facility. 
The doctors provides treatment to patients at the facility as they are unable to go out to see their primary care 
physician. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the members terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided July 16, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cancer 44-gene panel provided on 
February 23, 2022. 
 
You asked the Plan to pay for the comprehensive cancer 44-gene panel. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service 
of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 
analysis, or proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This testing is an NGS panel that was not billed with a single panel 
code as required. Based on this information, we decided that Medicare rules for coverage of the comprehensive cancer 44-gene panel have not been met. Therefore, we decided that the Plan does not have to pay for the 
comprehensive cancer 44-gene panel provided on February 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the F1Heme test is a proven medically 
necessary covered benefit for comprehensive genomic profile testing for cancer. The Plan denied your request. 
The Plan says does not meet Medicare NCD/LCD criteria.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Genetic testing procedures submitted with code 81455 are unlikely 
to impact therapeutic decision-making in the clinical management of the patient and will be denied 
automatically as not medically necessary. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for targeted genomic sequence analysis (81455) provided November 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered on June 21, 2021 to July 
18, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the provider is not Medicare-certified. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the 
dates of service at issue. Therefore, we decided that the Plan does not have to pay for the home health services 
rendered on June 21, 2021 to July 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continuation of SNF care is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
continued SNF care. 
 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 continued SNF care. Our reviewer says 
that the enrollee does not meet criteria for continued SNF care. Our physician reviewer found the enrollee is 
with diabetes, asthma, coronary artery disease (CAD), hypertension and bladder cancer. From a nursing 
perspective, the enrollee received oral and inhaled medications and insulin. The enrollee had stable vital signs. 
His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational 
therapy. The enrollee was independent with functional mobility including gait to greater than 200 feet. The 
enrollee was independent after set up with most activities of daily living. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to approve reimbursement for the emergency department visit (99285) and 
electrocardiogram, routine ECG with at least 12 leads (93010) provided November 7, 2021. 
 
You asked the Plan to approve reimbursement for the emergency visit. You say that please reimburse as soon 
as possible. The Plan denied your request. The Plan says that the services provided were medically necessary 
and payment was approved. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the plan or the 
enrollee.  
 
In this case, the record indicates that the Plan has paid the Medicare Allowed Amount for this service. A 
Medicare provider should accept the Medicare Allowed Amount as payment in full. In this case, the records 
show that the enrollee had paid the total amount of $1,260.00 to the provider on check dated 02/16/2022. The 
records also show that the Plan had also processed and paid to the provider the Medicare allowed amount on 
check dated 02/25/2022. The provider needs to reimburse the total amount of $1,260.00 back to the enrollee. 
The records provided show that the Plan has made attempts to contact the provider regarding the 
reimbursement but do not show that the provider has reimbursed the enrollee at this time. Therefore, we 
decided that the Plan has to approve reimbursement for the emergency department visit (99285) and 
electrocardiogram, routine ECG with at least 12 leads (93010) provided November 7, 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 laboratory services rendered on December 7, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services rendered on October 18, 
2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 88305 is not supported. 
 
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 88305 is Level IV surgical pathology gross and 
microscopic exam. 
 
We find that CPT code 88305 is not supported in the medical record. Specifically, the records show that a 
biopsy of the prostate was performed and there is a more appropriate code for these services. 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 pay for the surgical pathology services rendered on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid purchased on January 11, 2022, from a non-
contracted provider. 
 
You asked the Plan to pay for the hearing aid. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says you did not purchase the hearing aid from a contract 
provider. 
 
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. 
 Review of the file shows that you purchased a hearing aid on January 11, 2022, from a non-contracted 
provider. The health plan contract says that hearing services must be provided by a contracted provider. 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 hearing aid purchased on January 11, 2022, 
from a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an advanced replacement ankle-foot system and a new 
alignable system. 
 
You asked the Plan to pre-approve an advanced replacement ankle-foot system and a new alignable system. 
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 follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system 
(L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system 
(L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is 
covered for beneficiaries whose functional level is 3 or above. 
 
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 advanced replacement ankle-foot 
system and a new alignable system. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found in this case, you are a K3 functional ambulator and has a current K3 level ankle-foot 
system that is under warranty. The current alignable system can be used with your new components. The 
documentation does not support extenuating circumstances that would indicate a need for a new alignable 
system or new ankle-foot.  
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 advanced replacement ankle-foot system and a new alignable system have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced replacement 
ankle-foot system and a new alignable system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from October 29, 2021, 
through November 10, 2021. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of inpatient hospital care have not been met. J96.01 is not on the 
exempt list; therefore, it needs a value to be reported and not "1". Since it is blank, the claim is not coded 
correctly. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from 
October 29, 2021, through November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 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, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided from January 20, 2022, 
through March 8, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, acupuncture is only covered for chronic low back 
pain. Per the information submitted the diagnosis was for cervicalgia and pain in the thoracic spine, this is not a 
diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided from January 20, 2022, through March 8, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve admission to a SNF. Our reviewer says 
that the enrollee does not meet criteria for SNF admission. Our physician reviewer found the member has 
stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing 
and/or skilled therapy services on a daily basis. He is medically stable and can receive further rehab services at 
a lower level of care. Although further rehab services would be appropriate to improve function, as a practical 
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 
The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. 
He is medically stable without any acute exacerbations of chronic medical problems. His physical function is at 
or near his baseline and he can receive services at a lower level of care. Although placement may be needed for 
social issues at a custodial level, daily skilled care is not medically necessary. Admission to a SNF for inpatient 
skilled rehab services is not medically 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 26, 
2021. 
 
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 claim was submitted past the allowed 12 month timeframe. 
 
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 the services was not filed until February 15, 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 laboratory services provided to the enrollee on January 26, 2021.