Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occupational therapy services provided on June 3, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the occupational therapy services. You say that it was medically necessary to 
provide the services to the enrollee. The Plan denied your request. The Plan says the rendering provider is an 
OON provider and there was no referral from an in-network provider or an approved authorization. Also, the 
service rendered was not urgent or emergent. 
 
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 occupational therapy services provided on 
June 3, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 procedure code 83789 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 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
 
 
 
 
 We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
mass spectrometry of non-drug analyte(s). 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 
laboratory services rendered on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 4, 2022. 
 You asked the Plan to pay for the services provided. You say that the test identifies the primary tumor of 
origin. The Plan denied your request. The Plan says the date of service is inconsistent with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that there are insufficient medical records to determine if the billed date of service meets the Based on 
Medicare rules for coverage. Therefore, we decided that the Plan does not have to pay for the gene panel 
testing provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urine PCR (polymerase chain reaction) testing provided on 
April 12, 2022. 
 
You asked the Plan to pay for urine PCR testing. You say that this is a covered test which was denied as 
experimental in error. The Plan denied your request. The Plan says this testing is not medically necessary and 
reasonable. The standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and 
sensitivity. The PCR testing is considered unproven and not necessary. 
 
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 urine PCR testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the standard of care for the evaluation of urinary incontinence is urinalysis with urine culture and sensitivity. This PCR testing is considered unproven and 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 urine PCR testing have not been met. Therefore, we decided that the Plan does 
not have to pay for urine PCR (polymerase chain reaction) testing provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chronic care management services provided on April 18, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chronic care management services. You say that the services that were 
rendered to the enrollee does not require prior authorization. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 chronic care management services provided on 
April 18, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on March 15, 2022. 
 
You asked the Plan to pay for the testing services. You say that the test identifies actional gene alterations. The 
Plan denied your request. The Plan says the enrollee does not meet the guidelines. 
 
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. In this case, there are no medical records from the treating physician 
to show that the results of the testing would be used in the management of the enrollees specific medical 
problem.  Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the gene panel testing provided on March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aids (V5299, V5261) provided April 8, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you were not informed that the enrollee needed to 
purchase hearing aids from a specific provider. The Plan denied your request. The Plan says that the hearing 
aids are not covered because they were provided OON. 
 
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, the Plan has not provided the 2022 Evidence of Coverage or any 
plan documents that indicate that the supplemental hearing aid benefit only applies to in-network providers. 
Therefore, we decided that the Plan has to pay for the hearing aids (V5299, V5261) provided April 8, 2022, by 
an out-of-network (OON) provider.  
 
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 Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychotherapy visit provided on March 2, 2022 by an OON 
provider. 
 
You asked the Plan to pay for a psychotherapy visit. You say that you are requesting reconsideration stating 
numerous phone calls were made to the Plan regarding claim denials and you were given contradictory 
information on network status. The Plan denied your request. The Plan says the out-of-network services were 
not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a psychotherapy visit provided on March 2, 2022 
by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 18, 2022. 
 
You asked the Plan to pay for laboratory testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of physician pathology service must be the date the 
specimen was collected. The specimen in this case was collected on February 14, 2020, rather than the billed 
date of service April 18, 2022. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be billed with the 
date of specimen collection as the date of service. However, there are three exceptions to this rule. The rules 
also 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, the Plan has not acknowledged nor provided any argument to 
address the exceptions to the applied rule. The test in this case was performed on a live tumor sample and was 
performed over two years after the date of collection, so it is likely that an exception has been met in this case. 
Therefore, we decided that the Plan has to pay for laboratory testing (81455) billed for date of service April 18, 
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve push bars, a bag hook, cupholder and expandable 
controller (K0108, E2311, E2377, E2313) for a power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair accessories.. You say that these features are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for durable medical equipment that 
is mainly used to serve a medical purpose. Expandable controllers are covered when 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 the power wheelchair accessories.. Our 
reviewer says that the requested items are not medically necessary. Our physician reviewer found the push bar, 
bag hook, and cupholder are not primarily medical in nature and are not covered. The records show that the 
enrollee has upper extremity strength to control the power features through their own switches. The expandable 
controller 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 the power wheelchair accessories. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve push bars, a bag hook, cupholder and expandable controller (K0108, 
E2311, E2377, E2313) for a power wheelchair.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on 
January 19, 2022. 
 
You asked the Plan to pay for an emergency department visit. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 7, 2022. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for an emergency 
department visit provided on January 19, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is receiving the care they need in the hospital 
where they are now and there is no need to transfer to the LTACH currently. The enrollee can stay in the 
hospital until they are safe for transfer or discharge. 
 
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 transfer to the LTACH is not medically necessary as the enrollee is not stable for 
transfer and is critically ill. Completion of treatment at the current facility is recommended. 
 
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 LTACH services.
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 the enrollee needs to return to the LTAC 
for continued vent weaning and care. The Plan denied your request. The Plan says criteria for admission to the 
LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. 
 
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 was admitted to the acute care hospital with COVID-19 pneumonia, 
acute respiratory distress syndrome, acute respiratory failure, and acute renal failure in the setting of cirrhosis. 
The enrollee was treated with mechanical ventilation support, percutaneous endoscopic gastrostomy and trach 
placement, and anticoagulation complicated by encephalopathy. Recent notes describe the enrollee as 
following commands but still somewhat encephalopathic requiring restraints and there were no recent attempts 
to wean.  
 The enrollee appears to still be somewhat unstable and requires short-term additional acute care services that 
can safely be administered at the current facility until more appropriate for transfer. The enrollee does not 
require services at the LTACH that are not already available at the current 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the self-administered drugs (A9270) 
provided from April 9, 2022, through April 11, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not covered under 
your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to issue reimbursement for the self-
administered drugs (A9270) provided from April 9, 2022, through April 11, 2022.   
Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81518) provided on April 15, 2022. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81518 is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected (November 30, 2016). 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 (81518) provided on April 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on May 1, 2022. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says per the Medicare policy the ambulance benefit is a transportation benefit and if there is 
no transport, there is no benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 1, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport (code A0998) provided on May 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy visits. You say that you still need to continue physical 
therapy due to a medical diagnosis. The Plan denied your request. The Plan says the service can be provided by 
an in-network 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 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 
physical therapy visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 105 gene liquid biopsy provided on April 11, 2022. 
 
You asked the Plan to pay for the liquid biopsy. You say that this was medically necessary testing that should 
be paid. The Plan denied your request. The Plan says lab claims must be billed with the date of service 
reflecting when the sample was collected. This sample was collected on April 4, 2022, but April 11 was 
reported as the date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that lab claims may report the date the testing was 
performed only if the sample was taken during an outpatient hospital encounter, and it was medically 
appropriate to have collected the sample during said encounter. 
 
 
 
 We looked at the file and Medicare rules. In this case, there is no clear evidence that this sample was taken 
during an outpatient hospital encounter. Additionally, since the sample was peripheral blood, it is not clear that 
it was medically appropriate to have the sample taken during a hospital encounter rather than during an office 
visit. Without records from the date of sample collection, this cannot be confirmed. Based on this information, 
we decided that Medicare rules for coverage of the liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the 105 gene liquid biopsy provided on April 11, 2022.