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

 
We decided that the Plan does not have to pre-approve additional home health physical therapy visits. 
 
You asked the Plan to pre-approve home health visits. You say that the enrollee continues to require skilled 
therapy. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for the 
requested home health care. 
 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 home health visits. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested additional home health physical therapy. 
Our physician reviewer found the enrollee does not require additional skilled therapy services to effectively 
provide treatment, care, or services in order to improve the enrollee's condition or perform a maintenance 
program. The enrollee has been medically stable without any recent exacerbations of medical problems or 
hospitalizations. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (0037U) provided on February 21, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted. 
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Therefore, we decided that the Plan does not have to pay for the genetic 
testing (0037U) provided on February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are unable to receive the necessary time with 
rehabilitation and prefer not to go to a skilled nursing facility. The Plan denied your request. The Plan says you 
do not meet the Medicare criteria for IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  
 Our physician reviewer found you do not have the medical complexity to require rehabilitation physician 
supervision at least 3 times per week. While you may benefit from physical and occupational therapies, your 
needs can be safely met in a lower intensity alternate setting such as a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing services provided on November 22, 2021. 
 
You asked the Plan to pay for laboratory testing services. You say that you have provided records to support 
the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met. 
 
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. In this case, the Plan has denied for a lack of supporting medical documentation. 
The record documents that the Plan requested medical records two days prior to issuing their denial. A two-day 
return window does not constitute a reasonable and diligent effort to gather and forward the relevant medical 
records. It is the Plan's responsibility to substantiate its denial. In this case, the denial has not been 
substantiated, so we must find in your favor. Therefore, we decided that the Plan has to pay for laboratory 
testing services provided on November 22, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cold pad (E0218) you received on December 30, 2021. 
 
You asked the Plan to pay for the cold pad. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Per LCD L33735, the requested cold pad is not medically reasonable 
and necessary. Based on this information, we decided that Medicare rules for coverage of the cold pad have not 
been met. Therefore, we decided that the Plan does not have to pay for the cold pad (E0218) you received on 
December 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic treatment provided on April 12, 2022. 
 
You asked the Plan to pay for chiropractic treatment. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 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 chiropractic treatment provided on April 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 6, 2022. 
 
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 March 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service March 28, 
2022. 
 
You asked the Plan to pay for procedure code 83789. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 83789 is bundled into payment for code G0481. 
 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 83789 
is a column II code to column I code G0481. This claim has not been billed with an appropriate modifier to 
bypass the edit. The -59 modifier is not supported as a separate and distinct procedural service. Based on the 
claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure code 83789 billed for date of service March 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 4, 2022. 
 
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 must follow Medicare rules. The rules say that if Field 22 of the MFSDB contains an indicator of 0, 
2, or 3, the payment adjustment rules for bilateral surgeries do not apply. 
 
We looked at the file and Medicare rules. The file shows that the billed procedure code was not billed correctly 
per the indicator of "0" guidance. Therefore, we decided that the Plan does not have to pay for the surgical 
services rendered on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided on 
February 14, 2022. 
 
You asked the Plan to pay for the CGM. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery with an itemized list of the items received by the enrollee 
or relevant medical records which support medical necessity for the supplies provided in this case. The records provided do not support that the treating provider was planning to order a CGM for the enrollee in this case. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) provided 
on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 8, 2020, to 
July 14, 2020. 
 
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 submitted records do not support the billing of diagnosis code S06.6X9A.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code S06.6X9A. 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 these services. Our reviewer says that the submitted records do not 
support the billing of diagnosis code S06.6X9A. Our physician reviewer found the enrollee had a fall and head 
injury resulting in subdural hematoma with left humerus fracture. However, the patient was not reported to lose 
consciousness at the time. The records do not support that billed diagnosis code S06.6X9A is appropriate.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from July 8, 2020, to July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided February 16, 
2022. 
 
You asked the Plan to pay for the Cxbladder Detect testing. You say that this test is medically necessary and 
covered. The Plan denied your request. The Plan says this testing is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder Detect testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the Cxbladder Detect testing (0012M) provided February 16, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing (81161, 81286, 81413 81414, 81442, 81479) 
provided January 27, 2022. 
 
You asked the Plan to pay for the lab testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says insufficient information was provided to support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 lab testing (81161, 81286, 81413 
81414, 81442, 81479) provided January 27, 2022. have been met. The plan sent a request for a lab requisition 
and medical records to the provider. No additional records were submitted to support the service. Therefore, we 
decided that the Plan does not have to pay for lab testing (81161, 81286, 81413 81414, 81442, 81479) provided 
January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
May 4, 2022. 
 
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 must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all 
durable medical equipment (DME) and supplies. 
 
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed 
supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies rendered on May 4, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve consultation and follow-up with an out-of-network 
urogynecologist. 
 
You asked the Plan to pre-approve the OON uro-gynecology services. You say that this treatment is medically 
necessary as the enrollee's primary gynecologist felt that uro-gynecology consultation was necessary. The Plan 
denied your request. The Plan says that this is not a network provider. There are network providers available to 
provide the requested non-emergent care. 
 
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 complete list of network providers with sub-
specialization in uro-gynecology. The documentation simply states that such network providers exist; however, 
the Plan did not name these providers to allow review of accessibility or ensure that these services are available 
in a timely manner. Without confirmation of network adequacy, we find that the denial is not supported. 
Therefore, we decided that the Plan has to pre-approve consultation and follow-up with an out-of-network 
urogynecologist.  
 
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 genetic testing (81479) provided September 13, 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 this service was for screening purposes and is non-covered in this 
circumstance. 
 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, SelectMDx, 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 
genetic testing (81479) provided September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology services. You say that the services should be covered as 
you disagree with the denial, and that you have seen this provider before. The Plan denied your request. The 
Plan says the services denied correctly as they are non-emergent and can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthosis rendered on April 1, 2022. 
 
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 claim lines billed with codes without a KX, GA or GZ 
modifier will be rejected as missing information. 
 
We looked at the file and Medicare rules. The file shows that the claim was not biled with the required -KX 
modifier. 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 orthosis rendered on April 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 9, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 the laboratory services provided on 
November 9, 2021, have been met. In this case, the Plan made multiple attempts to obtain medical records for 
review with no response. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on November 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) and supplies 
provided on February 8, 2022. 
 
You asked the Plan to pay for the CGM and supplies. The Plan denied your request. The Plan says proof of 
delivery was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
continuous glucose monitor (CGM) and supplies provided on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 13, 2022. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
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 Plan says that the Plan has also determined that these services are not 
urgent or emergent, nor were they 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 requested provider in this case is not a network provider with the Plan. 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 a hospital outpatient clinic visit provided on May 13, 2022.