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

 
We decided that the Plan does not have to pay for the laboratory services provided on May 18, 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 covered as billed. 
 
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 laboratory 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 the laboratory services provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on October 4, 
2021. 
 
You asked the Plan to pay for code 0037U. 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. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(0037U) provided on October 4, 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. The Plan denied your request. The Plan says the enrollee's 
care is custodial. 
 
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 physician reviewer 
found that the enrollee was admitted to the hospital from home due to generalized weakness with falls. She 
received skilled rehab services in a skilled nursing facility until she was discharged home requiring custodial 
care. The most recent therapy documentation indicates the member is dependent for transfers and requires 
extensive assistance with mobility. This appears to be her new baseline until she is able to bear weight on the 
lower extremity. She is medically stable without any acute exacerbations of chronic medical problems.  Her 
physical function is at or near her new baseline. Therefore, an admission to a SNF for inpatient skilled rehab 
services is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second set of diagnostic facet blocks. 
 
You asked the Plan to pre-approve facet joint injections. You say that a single block was not effective. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because the 
enrollee received less than 80% pain relief from the previous injection. The Plan follows Medicare rules. Medicare rules state that a second confirmatory facet joint procedure may be 
covered if certain criteria are met, including that the first diagnostic facet joint procedure results in at least 80% 
relief of primary pain. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician 
reviewer found Medicare requires 80% pain relief from the first diagnostic injection, but the enrollee's first set 
of medial branch blocks did not achieve 80% pain relief. Therefore, this request is deemed not medically 
reasonable or 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a second set of diagnostic facet blocks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 28, 2020. 
 
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 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 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 provided on November 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen tank, to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a portable oxygen tank. You say that the item should be covered. The Plan 
denied your request. The Plan says there are suppliers in-network that can provide this item. 
 
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 
a portable oxygen tank, to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laparoscopy surgery services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has severe chronic daily 
pain. The Plan denied your request. The Plan says the enrollee's diagnosis is not indicated for this procedure. 
 
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 requested services. Our physician 
reviewer found that the documents indicate that the enrollee's ovaries were normal in appearance. It is noted 
that her insurance will not cover Lupron, and that she is declining Orilissa. She is requesting left-sided 
oophorectomy due to severe chronic daily pain. The clinical documentation does not support that a 
laparoscopic left oophorectomy is medically reasonable and necessary in this case, as no ovarian pathology has 
been identified. 
 
 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laparoscopy surgery services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says the claim has not been billed with an 
appropriate place of service. 
 
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 laboratory 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 the laboratory services provided on July 14, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the Femtosecond Laser assisted cataract surgery provided on 
September 9, 2021. 
 
You asked the Plan to pay for the Femtosecond Laser assisted cataract surgery. You say that this was to correct 
a macular hole in the eye and to fix a bleed in your eye. You say that your doctor felt that this was the safest 
and least traumatic procedure as your previous eye work was traumatic to the eye. The Plan denied your 
request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that health plans must pay for a medical service or item if 
regular Medicare would pay for it. Medicare coverage and payment for cataract surgery is the same irrespective 
of whether the surgery is performed using conventional surgical techniques or a bladeless, computer-
controlled laser. 
 
The issue in this appeal is not about the coverage for the cataract surgery but, rather, the method that the 
surgeon used to remove the cataract. The record shows that the surgeon employed the use of a Femtosecond 
Laser to make the incision to remove the cataract and insert the new intraocular lens. The rules say that cataract 
surgery is covered under Medicare regardless of whether the surgery is performed with a blade or a computer-
controlled laser. The record clearly shows that you received a conventional intraocular lens. This means that 
any services, regardless of the method used, that are part of cataract surgery with a conventional lens cannot be 
charged to the enrollee. In this case, we find that the Plan is required to reimburse you for any out-of-pocket 
fees you were charged for your cataract surgery. Therefore, we decided that the Plan has to pay for the 
Femtosecond Laser assisted cataract surgery provided on September 9, 2021.  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 19, 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 that they were unable to make a determination 
within the allotted time frame. 
 
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. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on November 19, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service (99100) provided on 
November 10, 2021. 
 
  You asked the Plan to pay for the special anesthesia service (99100). You say that your claim would fall under 
the facility authorization and should not have denied for no authorization. You say that the attached 
documentation should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The 
Plan says CPT code 00142 has been overturned and CPT code 99100 remains denied as bundled services are 
not eligible for separate reimbursement. 
 
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 99100 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage 
of the special anesthesia service (99100) have not been met. Therefore, we decided that the Plan does not have 
to pay for the special anesthesia service (99100) provided on November 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a privacy flap and cane holder (K0108) for a power 
wheelchair. 
 
You asked the Plan to pre-approve the privacy flap and cane holder. You say that these items are medically 
necessary. The Plan denied your request. The Plan says the requested features are not primarily medical in 
nature and are 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 privacy flap and cane holder (K0108) for a power 
wheelchair.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is a legitimate and evidence-based treatment for 
the enrollee's disease. The Plan denied your request. The Plan says that the denial of authorization for this 
service is correct, because this is not medically necessary. 
 
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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for this enrollee, curative intent type treatment would be considered an appropriate standard of 
care in the absence of widespread metastases. The advantages of SBRT are to allow dose escalation while 
minimizing the volume of normal tissue exposed to high dose radiation. These principles coupled with the 
medically standard application of SBRT to oligometastatic sites would suggest that standard medical necessity 
criteria are met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiation therapy (SBRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 27, 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 covered as billed. 
 
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 laboratory 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 the laboratory services provided on August 27, 2021.
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 any delay in transferring to a LTACH 
will directly jeopardize the enrollee's ability to fully recover and successfully regain maximum independence. 
The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at the current 
hospital. 
 
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. Our physician reviewer 
found the medical record does not indicate that the enrollee requires services that she is not currently receiving 
but that would be available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of skilled nursing facility (SNF) care after April 
27, 2022. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care remains medically 
necessary. The Plan denied your request. The Plan says that the criteria for SNF care after April 27, 2022 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 the continuation of SNF care. Our 
reviewer says that SNF care continues to be medically necessary. Our physician reviewer found that per 
clinical documentation, the criteria have been met for continued skilled nursing services due to complexity of 
wound care, ostomy care and monitoring of comorbidities. Per clinical documentation, you are recovering from 
acute medical condition still with mobility and self-care impairments and meets criteria for continued skilled 
therapy. The evaluating therapist well documents the complexity of the skilled therapy treatments due to 
multiple wounds and recent fall patient suffered. Nursing documents the complexity of the wound 
assessment/care and patient is being followed by the wound service. From a practical standpoint, 
documentation provides evidence that patient will continue to benefit from daily skilled nursing and skilled 
therapy in an inpatient setting, 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 the continuation of SNF care have been met. The Plan must continue coverage 
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has 
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-
approve the continuation of skilled nursing facility (SNF) care after April 27, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decipher Prostate Cancer Assay (81542) provided on 
September 2, 2021. 
 
You asked the Plan to pay for the Decipher Prostate Cancer Assay. 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. 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 Decipher Prostate Cancer Assay 
(81542) provided on September 2, 2021, have been met. Therefore, we decided that the Plan does not have to 
pay for the Decipher Prostate Cancer Assay (81542) provided on September 2, 2021.