Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in patient 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. The patient 
appears to be more stable and improving and should only require short-term additional acute care services that 
can safely be administered at the current facility until more appropriate for a lower level of care. The patient 
does not require services at the LTACH that are not already available at the current facility. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 29, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81291, 81355, 81335, 0031U, 0032U, 0033U, 81407, 81406 and 
81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
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 
March 29, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81291, 81355, 81335, 0031U, 0032U, 
0033U, 81407, 81406 and 81238.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on September 3, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that this should be reconsidered because you timely 
filed this claim. The Plan denied your request. The Plan says the member was on hospice on the date of service 
in question, so the Plan is not responsible for this bill. 
 
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 chest x-ray provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the commercial airline ticket purchased on 
February 27, 2022. 
 
You asked the Plan to reimburse you for the airline ticket. You say that you had to purchase an extra seat as a 
result of an injury sustained while on vacation. You also say that you expect to be reimbursed for this. The Plan 
denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the airline ticket have not been met. Specifically, Medicare doesnt cover the cost of commercial 
airline tickets and neither does the Plan. Therefore, we decided that the Plan does not have to reimburse you for 
the commercial airline ticket purchased on February 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a robotic arm device (E1399). 
 
You asked the Plan to pre-approve the robotic arm device. You say that the device is medically necessary. The 
Plan denied your request. The Plan says this device is not primarily medical in nature and is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a robotic arm device (E1399).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued inpatient skilled nursing facility (SNF) care 
provided from February 28, 2022, through March 29, 2022. 
 You asked the Plan to pay for the continued SNF care. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the services provided in this case were 
not medically necessary. 
 
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 continued SNF care. Our reviewer says 
that the continued inpatient skilled nursing facility care provided was not medically necessary. Our physician 
reviewer found that based on the medical records provided, daily skilled services were not required. The 
enrollee was walking household distances with a rolling walker with contact guard assistance and was 
supervision to contact guard assistance for transfers. As a practical matter, the enrollee did not require the 
necessary services on an inpatient basis, only in a skilled nursing facility setting. In this case, the services in the 
nursing facility appear to have been custodial care provided. 
 
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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pay for the continued inpatient skilled nursing facility (SNF) care provided from February 28, 
2022, through March 29, 2022.
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the enrollee appears to be improving but is still somewhat unstable and should only 
require short-term additional acute care services that can safely be administered at the current facility until 
more stable and appropriate for a lower level of care. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to LTACH is not medically 
necessary as the enrollee is not yet stable for transfer and as it would not be clinically advantageous. 
Completion of treatment at the current facility is recommended at this time. 
 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 lab services provided on March 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and were billed 
appropriately. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on March 14, 2022. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare Part B covers cardiovascular disease screening tests when ordered by the physician 
who is treating the beneficiary for the purpose of early detection of cardiovascular disease in individuals 
without apparent signs or symptoms of cardiovascular disease. 
 
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 only the following codes are covered for cardiovascular disease screening: CPT code 80061 (Lipid panel) which includes CPT codes: 82465 (Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct 
measurement; high density cholesterol) and/or 84478 (Triglycerides). 
 
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 cardiac risk assessment genetic screening testing provided to the enrollee on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service November 
19, 2021. 
 
You asked the Plan to pay for procedure code 99100. You say that the claim should be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says procedure code 99100 is considered 
bundled and not separately 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 code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service November 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities (97530), and self-care/home 
management training (97535) provided on February 22, 2021. 
 
You asked the Plan to pay for the rehabilitation services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim denied correctly. 
 
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 rehabilitation services was not filed until March 21, 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 the therapeutic activities (97530), and self-care/home 
management training (97535) provided on February 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 6, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 procedure code 70450 billed for date of service April 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long term 
acute care admission. The Plan denied your request. The Plan says the medical records do not show that the 
enrollee meets Medicare guidelines. The enrollee is receiving appropriate inpatient acute care and does not 
require transfer to a 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 the enrollee is receiving appropriate care at the present setting. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where they are currently 
receiving care. 
 
 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay the full amount for office visit (99211), and determination of refractive 
state (92015) provided on April 14, 2022. 
 
You asked the Plan to pay the full amount for the vision care. You say that the services should be covered. The 
Plan denied your request. The Plan says that the eye refraction service is not covered since it was a medical 
vision check. 
 
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. Specifically, it is reasonable that the enrollee would expect the office visit to be 
covered in full, as listed in the Plan contract. The record does not indicate that a medical exam was performed 
versus a routine exam. Additionally, the record indicates that the diagnosed cataracts are being treated by a 
provider other than the treating provider in this case. Therefore, we decided that the Plan has to waive the 
copayment amount for office visit (99211), and pay for the determination of refractive state (92015) provided 
on April 14, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive medicine reevaluation, the electrocardiogram, 
and the laboratory work provided on May 5, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the preventive medicine reevaluation, the electrocardiogram, and the laboratory 
work. You say that the services were medically necessary. The Plan denied your request. The Plan says no 
prior authorization was obtained. 
 
 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 
preventive medicine reevaluation, the electrocardiogram, and the laboratory work. We found no exception that 
would require the Plan to pay for the preventive medicine reevaluation, the electrocardiogram, and the 
laboratory work vices. The record shows CPT code 36415 was billed which means the provider had the 
opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have 
to pay for the preventive medicine reevaluation, the electrocardiogram, and the laboratory work provided on 
May 5, 2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you say the enrollee needs SNF care. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the medical records do not document that 
you require services on an inpatient basis, only in a skilled nursing facility. 
 
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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the astigmatism-correcting function of intraocular lenses (A-
C IOLs) (V2787) provided on March 2, 2022, and April 6, 2022. 
 
You asked the Plan to pay for the A-C IOLs. You say that you believe these services should be covered. The 
Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism-
correcting function of intraocular lenses (A-C IOLs) (V2787) provided on March 2, 2022, and April 6, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) stay provided from 
December 2, 2021, to December 16, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the SNF stay. You say that per a prior phone conversation only a notification was 
needed and done prior to admit. The Plan denied your request. The Plan says there was no authorization for 
service for this provider nor were they approved in advance. 
 
We found no exception that would require the Plan to pay for these items/services. Prior authorization is 
required for inpatient skilled nursing care. Therefore, we decided that the Plan does not have to pay for a 
skilled nursing facility (SNF) stay provided from December 2, 2021, to December 16, 2021, by an out-of-
network provider.