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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided from January 
1, 2022, to January 31, 2022. You asked the Plan to pay for SNF care. You say that the Plan has paid $0 for these services rather than the 
allowable for HIPPS code KGSF1. The Plan denied your request. The Plan says this claim was not submitted 
with the necessary line for the HIPPS code and a corrected claim is necessary to process payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
SNF Pricer shall determine the rate for SNF care using the HIPPS code submitted on line item 0022. 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. The submitted claim does not include line item 0022 with the 
appropriate HIPPS code. Without this information, there is insufficient information to calculate payment. 
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 
from January 1, 2022, to January 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast reduction and abdominoplasty surgery. 
 
You asked the Plan to pre-approve breast reduction and abdominoplasty surgery. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that cosmetic surgery is only covered for certain 
indications. 
 
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 breast reduction and abdominoplasty 
surgery. Our reviewer says that the documentation does not support that the requested services are medically 
reasonable or necessary. Our physician reviewer found the enrollee has hypertrophy of the breasts. The enrollee 
has a calculated BSA of 1.92 m2. The estimated gram amount to be removed from each breast is 628. There is 
insufficient documentation that the surgeon's estimate of breast size/weight/volume to be removed is 
proportional to the BSA per the Schnur scale per breast. The clinical documentation does not support that the 
enrollee has any signs or symptoms resulting from the enlarged breasts that have not responded adequately to 
non-surgical interventions. The clinical documentation does not support that the enrollee has dermatologic 
signs or symptoms are refractory to or recurrent following a completed course of medical management. There 
is no clinical documentation of intertriginous maceration, discoloration, chronic or recurrent infection of the 
inframammary skin refractory to dermatologic treatment measures, or shoulder grooving to a depth greater than 
1 cm with skin irritation or darkening by supporting garment. Therefore, the enrollee does not meet criteria for 
the requested 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 breast reduction and abdominoplasty surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve breast reduction and abdominoplasty surgery.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (0037U) provided March 25, 2022 . 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that genetic testing panels that test for the FANCC gene are non-covered 
per Medicare Local Coverage Article: Billing and Coding: MolDX: FANCC Genetic Testing (A53628). 
 
The Plan must follow Medicare rules. Medicare rules say that effective for services performed on or after 
March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation 
Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally. 
 
We looked at the file and Medicare rules. The denial is based upon a local coverage decision. A local coverage 
determination cannot support the denial of a nationally-covered service. Based on this information, we decided 
that Medicare rules for coverage of the genetic testing have been met. Therefore, we decided that the Plan has 
to pay for genetic testing (0037U) provided March 25, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care (99291) provided on August 21, 2020. 
 
You asked the Plan to pay for the critical care. You say that the timeframe to submit health claims has been 
extended to 60 days after the announcement of the end of the current National Emergency. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the critical care was not filed until August 23, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the critical care (99291) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that the rendering physician is a hospitalist physician 
with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization 
from the patient's insurance company. The Plan denied your request. The Plan says services from non-
participating providers are not covered unless preauthorized. 
 
 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 March 4, 2022, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76770 billed for date of service April 4, 
2022. 
 
You asked the Plan to pay for procedure code 76770. You say that this is not a bundled charge. The Plan 
denied your request. The Plan says payment for code 76770 is bundled into payment for code 93976. 
 
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 76770 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76770 billed for date of service April 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantation of spinal cord stimulator. 
 
You asked the Plan to pre-approve the implantation of spinal cord stimulator. You say that this is necessary to 
treat the enrollees pain. The Plan denied your request. The Plan says the requirements for coverage have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that a spinal cord stimulator trial can be covered only for 
patients who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to 
implantation. Such screening must include a psychological evaluation.  
 
The file does not show that a psychological evaluation has been conducted in conjunction with this request for 
a spinal cord stimulator trial. Therefore, we decided that the Plan does not have to pre-approve the implantation 
of spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 1, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not informed that out of network providers 
were only covered if an approved prior authorization was obtained in advance. The Plan denied your request. 
The Plan says there is no referring provider on the claim, so the Medicare Rule of Plan Directed Care does not 
apply. The provider is out of network on the members plan, and per the members Summary of Benefits and 
Coverage, out of network providers may not be 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 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 April 1, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on January 12, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs dispensed in office (D9630), socket preservation 
(D7953), localized delivery of antimicrobial agent (D4381), and periodontal scaling and root planing (D4341, 
D4342 and D4921), provided by a participating provider on April 29, 2022. 
 
You asked the Plan to pay for drugs dispensed in office, socket preservation, localized delivery of antimicrobial 
agent, and periodontal scaling and root planing. You say that these services were medically necessary. The Plan 
denied your request. The Plan says these services have been correctly denied. 
 
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, D9630, D7953 and D4381 are not 
among those covered under this benefit. D4341, D4342 and D4921 have been exhausted. Therefore, we decided that the Plan does not have to pay for drugs dispensed in office (D9630), socket preservation (D7953), 
localized delivery of antimicrobial agent (D4381), and periodontal scaling and root planing (D4341, D4342 and 
D4921), provided by Aspen Dental on April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that there is no contractual 
agreement in place which indicates that the CPT codes billed are included in the dialysis rate. The Plan denied 
your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services provided on April 25, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for wound care services. You say that the member is a resident of a nursing home 
where wound care supplies have been delivered to treat their wounds. You also say that these supplies do not 
require authorization/referral. The Plan denied your request. The Plan says this provider is not a network 
provider with the Plan. The Plan also says that they  have determined that these services are not urgent or 
emergent, nor were they approved in advance.  
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 wound care services provided on April 25, 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 Tempus xG Hereditary Cancer Panel Test provided 
February 16, 2022. 
 
You asked the Plan to pay for the Tempus xG Hereditary Cancer Panel Test. You say that this genetic testing is 
medically necessary. The Plan denied your request. The Plan says this service does not meet criteria for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved.  
 
We looked at the file and Medicare rules. Research shows that the Tempus xG Hereditary Cancer Panel Test is 
not FDA approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xG 
Hereditary Cancer Panel Test have not been met. Therefore, we decided that the Plan does not have to pay for 
the Tempus xG Hereditary Cancer Panel Test provided February 16, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on November 19 through December 15, 
2021. 
 
You asked the Plan to pay for the home health services. You say that the CBSA is on the claim and is a valid 
code. The Plan denied your request. The Plan says that they need the claim to be billed on a CMS 1500 form. 
The Plan says that they have tried to obtain a correct claim from the provider but have not received one. 
 
The Plan must follow Medicare rules. Medicare rules say that institutional providers, including home health 
agencies, use one of two institutional claim formats to bill Original Medicare. In the great majority of cases, 
these providers are required to use the electronic HIPAA standard institutional claim transaction, the 837I. The 
minority of providers that are eligible for an exception to electronic claim submission use the paper Form 
CMS-1450, also known as the UB-04. 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plans reason for 
denial has not been substantiated. Therefore, we decided that the Plan has to pay for home health services 
provided on November 19 through December 15, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT). 
 
You asked the Plan to pre-approve PBRT. 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 PBRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is insufficient prospective, long-term clinical data available to determine whether or not 
proton beam radiation therapy for prostate cancer is superior, inferior or equivalent to external beam radiation 
therapy, Intensity-modulated radiation therapy (IMRT), or brachytherapy with regards to safety and efficacy. 
The most recent AUA guidelines state that proton beam therapy (PBT) offers no clinical advantage over other 
forms of definitive treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation Therapy (PBRT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on December 24, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the podiatry services. You say that you would like the claim reprocessed and 
paid as an in-network provider. 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 podiatry services provided on December 24, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on May 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 domiciliary services provided on May 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 genetic testing provided on November 4, 2021, billed 
with codes 81479, 81406, 81405, 81404, 81403 and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported as billed. The Plan denied your request. The Plan says the documentation provided does not support 
the billing of more than one panel code in this case. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. The documentation provided does not support that more than one panel was requested or 
administered. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on November 4, 2021, billed with codes 81479, 81406, 81405, 81404, 81403 and 81401.