Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services with a sports medicine doctor. 
 
You asked the Plan to pre-approve the consultation services with a sports medicine doctor. You say that the 
medical records provided support the need for a consultation with the sports medicine doctor. The Plan denied 
your request. The Plan says there is no referral from the enrollee's PCP for the consultation services from a 
sports medicine doctor. 
 
Medicare rules say that plans can require enrollees obtain authorization before receiving services. The contract 
with the Plan says that the enrollee needs to get a referral from their PCP to see network specialists.  
 
The requested provider in this case is a specialist. The records show that a physician assistant within an orthopedic group referred the enrollee to see the requested specialist. There is no record of the enrollee's PCP 
referring them to see the requested specialist. We found no exception that would require the Plan to pre-
approve these services. Therefore, we decided that the Plan does not have to pre-approve consultation services 
with a sports medicine doctor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total laryngectomy and radical neck dissection 
procedure. 
 
You asked the Plan to pre-approve a total laryngectomy and radical neck dissection procedure. You say that 
your cancer has returned and is metastasizing rapidly. You say that you are having difficulty breathing and 
swallowing. You say that the cancer could spread all over your body without the requested surgery. The Plan 
denied your request. The Plan says they did not obtain information from the enrollee's doctor to support 
medical need for the requested procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 a total laryngectomy and radical neck 
dissection procedure. have been met. The case file shows that the Plan made reasonable attempts to obtain medical records. Therefore, we decided that the Plan does not have to pre-approve a total laryngectomy and 
radical neck dissection procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stockings (A6549 x 8). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the compression stockings requested are not a covered 
benefit by Medicare or the Plan.  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
non-covered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient 
compression stockings (A6549 x 8).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 13, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care.  The patient was admitted for a diabetic foot ulcer and had a below the knee amputation. The enrollees medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that 
this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on February 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the member's primary care physician did not refer these services. 
 
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 physical therapy provided on February 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 targeted genomic sequence analysis, solid organ 
neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, 
gene rearrangements, microsatellite instability and tumor mutational burden (0037U) provided December 22, 
2021. 
 
You asked the Plan to pay for the FoundationOne CDx (F1CDx) test. You say that the provision of F1CDx to 
the enrollee meets the requirements of the NCD and has been determined by CMS to be reasonable and 
necessary for the management of the enrollees advanced cancer. The Plan denied your request. The Plan says 
the next generation sequence testing (NGS) testing panel performed included testing for the FANCC gene. 
Testing for this gene is not a Medicare benefit and is statutorily excluded service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the FoundationOne CDx test have not been met. Therefore, we decided that the Plan does not have 
to pay for the targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, 
interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite 
instability and tumor mutational burden (0037U) provided December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee has tighter control of her 
blood sugars. The Plan denied your request. The Plan says the criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan drops. 
 
You asked the Plan to pre-approve Rocklatan drops. You say that the requested drug is medically necessary. 
The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says 
self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
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 pre-approve Rocklatan drops.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nuclear medicine services (78472, A9560) provided on 
January 12, 2022. 
 
You asked the Plan to pay for nuclear medicine. You say that these services were medically necessary and were 
billed appropriately. The Plan denied your request. The Plan says this claim was billed with diagnosis code 
Z79.899, which is not supported as a medically necessary diagnosis for this service per the Local Coverage 
Article. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules also say that there are specific diagnosis codes which support the medical necessity of CPT code 78472. 
Any diagnosis codes that are not listed do not support the medical necessity of CPT code 78472. 
 
We find that these services are not supported in the medical record. Specifically, the diagnosis code billed on 
this claim are not included on the list of appropriate diagnosis codes to support the medical necessity of CPT 
code 78472. Based on this information, we decided that Medicare rules for coverage of nuclear medicine have 
not been met. Therefore, we decided that the Plan does not have to pay for nuclear medicine services (78472, 
A9560) provided on January 12, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that skilled nursing facility care is medically necessary 
for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an SNF are not met. 
The enrollee does not require daily skilled nursing services and daily therapy at this level of care. 
 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 care. Our reviewer says that SNF 
care is not medically necessary for this enrollee. Our physician reviewer found based on the documentation 
provided, the enrollee does not meet the criteria for SNF coverage. The enrollee does not have documented 
skilled nursing needs which require the specialized skill, knowledge and judgement of professional nurse in 
order to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not 
have documented skilled therapy needs which require the specialized skill, knowledge and judgement of a 
qualified therapist. Daily skilled services are not shown to be required to establish a maintenance program or to 
prevent deterioration of the enrollee's condition, and therefore SNF care is not medically necessary in this case. 
 
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 pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940/98941), 
therapeutic exercises (97110), and the manual therapy (97140) rendered by the out-of-network (OON) provider 
on February 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98940/98941), therapeutic exercises 
(97110), and the manual therapy (97140) rendered by the out-of-network (OON) provider on February 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 
24-hour facility coded 99053 and the rhythm electrocardiogram (ECG) coded 93042 provided on December 31, 
2021.  
You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility and 
the rhythm electrocardiogram (ECG). You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services are not payable as 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. We find that CPT code 99053 is not supported 
in the medical record. Specifically, this code has a status code of B. This means that payment for this service 
is always bundled into payment for other services not specified and no separate payment can be made. 
 
In this case, we have confirmed that code 93042 is a column II code to column I code 99291. 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 the service(s) provided 
between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 and the rhythm electrocardiogram (ECG) 
coded 93042 provided on December 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility, at home with home health services or at home with outpatient 
therapy. 
 
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 while the enrollee has a need for physical and/or occupational therapy, there is 
no documentation of a need for an intensive rehabilitation program such as 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 imaging services provided to the enrollee on June 29, 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 these services are not paid separately when the patient is inpatient. 
 
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 73610 is "Radiologic examination, ankle; complete, 
minimum of 3 views." 
 
We find that CPT code 73610 is not supported in the medical record. Specifically, the enrollee was inpatient at 
this time. This service would not be paid separately when the enrollee is inpatient. 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 imaging services provided to the enrollee on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on September 21, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office or other outpatient visit (99213) 
and ophthalmic diagnostic imaging (92134) provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for an office or other outpatient visit and ophthalmic diagnostic 
imaging. You say that the claim at issue was incorrectly processed. The Plan denied your request. The Plan 
says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $75 copayment for an office or other outpatient visit with ophthalmic diagnostic 
imaging.  Ophthalmic diagnostic imaging falls within the "Outpatient diagnostic tests and therapeutic services and 
supplies" benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office or other 
outpatient visit (99213) and ophthalmic diagnostic imaging (92134) provided on January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the refraction provided on December 1, 2021. 
 
  You asked the Plan to pay for the refraction. You say that you had post operative issues after cataract surgery 
that made a refraction impossible during the normal timeframe. You say that it wasn't until November that a 
refraction could be performed, and the $98 charge should be approved. The Plan denied your request. The Plan 
says the refraction is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services. Therefore, we decided that 
the Plan does not have to pay for the refraction provided on December 1, 2021.