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

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis testing (code 81455) 
provided on April 12, 2022. 
 
You asked the Plan to pay for genetic testing. You say that this testing was medically necessary to assist in the 
treatment, prognosis, and diagnosis of the enrollee's condition. The Plan denied your request. The Plan says this 
testing was billed with an inappropriate date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service billed for clinical laboratory 
testing/services must generally be the date that the specimen was collected.  
 
We looked at the file and Medicare rules. The date of service billed on this claim does not match the date that 
the specimen was collected for this testing. The record does not show why this testing would be an exception to 
the general date of service rule. Based on this information, we decided that Medicare rules for coverage of 
genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for targeted 
genomic sequence analysis testing (code 81455) provided on April 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 13, 2022, by an OON 
provider. 
 
You asked the Plan to pay for an office visit. 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 an office visit provided on June 13, 2022, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on May 11, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that the insurance card that the patient 
presented indicated that they had a PPO plan, so no authorization should have been needed. The Plan denied 
your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 in this case is not a network provider with the Plan. 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 medical services provided on May 11, 2022 by an out-of-network (OON) 
provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 6, 2022, by an OON 
provider. 
 
You asked the Plan to pay for laboratory services. You say that the enrollee did not know the laboratory was 
out-of-network.  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 laboratory services provided on May 6, 2022, by 
an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, and 88360 billed for date of 
service January 14, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, and 88360. You say that you disagree with the 
denial. The Plan denied your request. The Plan says the codes are included in the skilled nursing facility 
payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT codes 88341, 88342, and 88360 have a Professional/Technical indicator of 1. This means that 
CPT codes 88341, 88342, and 88360 have both a professional and technical component. In this case, CPT 
codes 88341, 88342, and 88360 have not been billed with an appropriate modifier to indicate the professional 
component. Based on this information, we decided that Medicare rules for coverage of procedure codes 88341, 
88342, and 88360 have not been met. Therefore, we decided that the Plan does not have to pay for procedure 
codes 88341, 88342, and 88360 billed for date of service January 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency ambulance transportation provided on 
February 1, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that you would like to 
request retro authorization for this service. The Plan denied your request. The Plan says unauthorized, out-of-
network services are not covered. You did not have authorization for this non-emergency transportation. 
 
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. 
 Your organization is not a network provider with the Plan. 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 non-emergency ambulance transportation provided on February 
1, 2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received from June 2, 2022, to June 
7, 2022. 
 
You asked the Plan to pay for the drugs. You say that this should be paid for. The Plan denied your request. 
The Plan says this is never covered 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 requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
from June 2, 2022, to June 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on February 22, 2021. 
 
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Medicare 
denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year 
from the date the services were furnished. 
 
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 ambulance services was not filed until April 25, 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 ambulance services provided on February 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (J9271), J9045 Carboplatin,J9171 Docetaxel, 
J2469 Palonosetron, J1100 Dexamethasone, and J1453 Fosaprepitant IV. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drugs. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found that the patient has 
progressed on prior immunotherapy and last dose less than 6 months ago. This requested regimen is not 
recommended for 1st line therapy. These drugs would not be considered safe and effective for the enrollee.  
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda (J9271), J9045 Carboplatin,J9171 Docetaxel, J2469 Palonosetron, J1100 
Dexamethasone, and J1453 Fosaprepitant IV.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a reflective winter jacket provided on May 13, 2022, by an 
OON provider. 
 
You asked the Plan to pay for a reflective winter jacket. The Plan denied your request. The Plan says this is a 
non-covered service. 
 
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 reflective winter jacket provided on May 13, 
2022, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography (procedure code 95861 and 95869) 
provided to the enrollee on November 4, 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 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95869: 
 
Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12)  
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 that procedure code 95861 and 95869 
is not supported by the medical records submitted, due to the report not including documentation of a needle 
electromyography of 2 extremities with or without related paraspinal areas or Needle electromyography; 
thoracic paraspinal muscles (excluding T1 or T12). 
 
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 needle electromyography (procedure code 95861 and 95869) provided to the enrollee on 
November 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 9, 2020, to February 17, 2020. 
 
You asked the Plan to pay for SNF care. You say that the discharge date was not chosen by the family. The 
Plan denied your request. The Plan says services in the SNF were no longer appropriate after February 8, 2020. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that as of 2/9/2020, the enrollee did not require any skilled nursing or rehab services 
on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of 
time or require skilled therapy to prevent deterioration with mobility or ADLs. The enrollee did not require 
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not 
require any skilled services on an inpatient basis, at a SNF level of care as of 2/9/2020. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from February 9, 2020, to February 
17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
January 25, 2022, to January 31, 2022. 
 
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 DRG was updated.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 services at issue in this case were not supported by the medical records. 
Our physician reviewer found that there was no report of sputum/respiratory culture result. The diagnosis codes 
for sepsis and severe sepsis are not supported by the hospital record for this hospital encounter. The more 
appropriate principal diagnosis in this case is pneumonia. The review has determined that the appropriate DRG 
was DRG 202: BRONCHITIS AND ASTHMA WITH CC/MCC.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from January 25, 2022, to January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 25, 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 81455 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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, the file shows that the 
specimen was not collected ont he billed date of service. 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 April 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF system. 
 
You asked the Plan to pre-approve a CardioMEMs HF system. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 a CardioMEMs HF system. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there remains a dearth of randomized, blinded clinical studies examining 
long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this 
time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollees 
clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMs HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMs HF system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 9, 2022 by 
an OON provider. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that you are appealing the date of 
service and have submitted medical records for reconsideration. 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 hospital outpatient clinic visit provided on June 
9, 2022 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to be transferred to a rehabilitation facility 
as soon as possible and you cannot stay in the hospital as you require extensive care. The Plan denied your 
request. The Plan says the criteria for admission to an IRF are not met; the care you need can be safely 
provided in a less intensive setting. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on May 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on June 1, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the chest x-ray rendered on May 17, 2022.