Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous glucose monitor (CGM) sensors (K0553) 
provided on January 1, 2022. 
 
You asked the Plan to pay for CGM sensors. You say that the items at issue were a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the case 
record does not include valid proof of delivery. 
 
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 for the supplies provided 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 continuous glucose monitor (CGM) sensors (K0553) provided on 
January 1, 2022.  
 
Your complaint about the Plans bully tactics and harassment in denying claims for the enrollee in this case 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit (99211) provided on January 10, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that all COVID tests are free for citizens, and you would 
like the claim to be reprocessed and paid. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient office visit (99211) provided on January 
10, 2022 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caris Molecular Intelligence(r) tumor testing (CPT code 
81479). 
 
You asked the Plan to pre-approve the service. You say that the testing needs to be performed so the correct 
medication can be prescribed. The Plan denied your request. The Plan says the test is not medically necessary, 
is considered experimental/investigational, and is not a covered benefit. 
 
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 the service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are 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 the service have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Caris Molecular Intelligence(r) 
tumor testing (CPT code 81479).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 fractions of 3-dimensional (3D) conformal image guided 
radiation therapy (IGRT). 
 
You asked the Plan to pre-approve 3D conformal IGRT. You say that you want to use 3D conformal IGRT to 
minimize dose and avoid hot spots to the esophagus/heart and subsequent side effects. The Plan denied your 
request. The Plan says that the denial of authorization for this service is correct, because it would be within the 
accepted standards of care to use 2-dimensional (2D) radiation and the enrollee has widely metastatic disease 
and treatment is palliative, so image guided radiation therapy (IGRT) is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 3D conformal IGRT. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for this enrollee, with cord compression and a partially collapsed vertebra, the treatment is 
more complex as compression fractures and cord compression imply the bone is disrupted and thus the target 
would include an extraosseous component. For bone metastases in the context of an extraosseous component, 
3D radiation is an accepted standard. Therefore, this treatment meets guidelines for what necessitates 3D 
radiation and as such treatment would be within the accepted standards of 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 3D conformal IGRT have been met. Therefore, we decided that the Plan has to 
pre-approve 10 fractions of 3-dimensional (3D) conformal image guided radiation therapy (IGRT).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services provided to the enrollee on May 11, 
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 an add-on code is not covered when there is no appropriate primary code reported for the same 
day. 
 
 
 
 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 99292 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for critical care services provided to the enrollee on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (87150, 87324) provided June 21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
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 (87150, 87324) provided June 21, 2021.
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 the enrollee's family insists on the inpatient 
rehabilitation level of care while the enrollee continues ongoing therapies. The Plan denied your request. The 
Plan says the requirements for care in an inpatient rehabilitation setting have not been met, therefore the 
requested services have been denied as there is no medical necessity for this level of 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 the enrollee does not have any complex nursing or rehabilitation needs that 
would require an acute inpatient rehabilitation stay. While the enrollee does have a need for physical therapy 
and/or occupational therapy, there is no evidence of a need for an intensive rehabilitation program. There is no 
reasonable expectation that the enrollee would fully participate in and benefit from an intensive rehabilitation 
program provided in an IRF. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 29, 
2021. 
 You asked the Plan to pay for subsequent hospital care. You say that this service was billed appropriately and 
is supported in the record. The Plan denied your request. The Plan says the payment for this service is included 
in the payment for 51865, which was billed for October 28, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, payment for CPT code 99232 is included in the 
global surgery package for CPT code 51865. Of note, CPT code 99232 has not been billed with the required 
modifier to indicate that this service would be separately payable. Therefore, we decided that the Plan does not 
have to pay for subsequent hospital care (99232) provided on October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary for your 
quality of life. The Plan denied your request. The Plan says that your current level of function is close to your 
baseline and the services you require, help with your care and intermittent therapy, can safely be received at a 
different setting 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth evaluation and management services (99443) 
provided on September 30, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the telehealth services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the telehealth evaluation and management services 
(99443) provided on September 30, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) facility. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial and would like the Plan 
to reconsider coverage. The Plan denied your request. The Plan says the enrollee does not qualify to see an out-
of-network provider because the SNF admission is not emergent, there are in-network providers available to 
the member in her service area and the service requested is not dialysis for end stage renal disease. 
 
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 
skilled nursing facility (SNF) care to be provided by an out-of-network (OON) facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) testing provided to 
the enrollee on December 23, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says this type of testing is considered unproven. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has incontinence, recent urinary tract infection, and treatment a few weeks prior. PCR 
testing for urine organisms was requested. The provided documentation did not describe a return or worsening 
of symptoms to support testing. Also, there was no documented contraindication to urinalysis testing or 
standard urine culture. Therefore, without support made for this request, the PCR testing will be considered not 
medically necessary based on the provided documentation.  
 
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 urine polymerase chain reaction (PCR) testing provided to the enrollee on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on March 26, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that the services at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have 
not been met. 
 
 
 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 services provided on March 26, 2021, 
by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement services provided to the enrollee on February 
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 records do not support the services billed. 
 
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 the denied codes is: 
 
CPT 11044: 
 
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 
20 sq cm or less 
 
 
 CPT 11047: 
 
Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each 
additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 
 
We asked our coder 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 supported by the medical records. Our reviewer found the operative report describes 
debridement and readvancement of omental flap. In this case, debridement was performed for the creation of 
omental flap and therefore would not be reported separately.  
 
We looked at this coder'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 debridement services provided to the enrollee on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) provided on November 10, 2021. 
 
You asked the Plan to pay more for the crown. You say that you would like this bill to be paid because it is for 
a crown. The Plan denied your request. The Plan says your cost share was calculated correctly. The Plan also 
says that cost sharing is a contractual obligation of the Plan and cannot be waived. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for a 50% 
coinsurance for the crown (D2740). Therefore, we decided that the Plan does not have to pay more for the 
crown (D2740) provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3020) provided on October 11, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that the item at issue was a medical necessity for you. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 do not show that you suffer from diabetic foot disease or that you 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 pay for foot orthotics (L3020) provided on October 11, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 81276, 
81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194) provided September 3, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. Code 81479 is being reimbursed for the 
panel. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic 3 analysis, 
or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the 
laboratory may report CPT code 81479. 
 
We looked at the file and Medicare rules. Multiple unbundled codes were submitted for a single panel. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81272, 81275, 
81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321, 81194) provided September 3, 2021.