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

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis rendered on July 7, 
2021. 
 
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 services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that targeted genomic sequence analysis is covered 
when specific criteria are met. 
 
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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has malignant neoplasm of 
the endometrium. The available documentation does not support that the enrollee displays clinical features of 
an associated disease, that the result of the test will directly impact the treatment being delivered, and that a 
definitive diagnosis remains uncertain after history, physical examination, pedigree analysis, genetic 
counseling, and completion of conventional diagnostic studies. The documentation does not support that the 
genomic testing in this case was medically reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the targeted genomic sequence analysis rendered on July 7, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOneCDx (F1CDx) testing provided on August 26, 2021. 
 
You asked the Plan to pay for the F1CDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
In this case, the file shows that the specimen was stored for more than 30 calendar days before testing. Based 
on this information, we decided that Medicare rules for coverage of the F1CDx testing have been met. 
Therefore, we decided that the Plan has to pay for the FoundationOneCDx (F1CDx) testing provided on August 
26, 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: 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 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you do not have an 
agreement to include these services 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 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network portion of an outpatient 
procedure provided on March 21, 2022. 
 
You asked the Plan to waive the coinsurance for an out-of-network portion of an outpatient procedure. You say 
that you've had this done before and did not need to pay an extra coinsurance. The Plan denied your request. 
The Plan says the coinsurance applied was correct. 
 
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 50% 
coinsurance for out-of-network surgical services. The allowed amount of this cost is $108.12 resulting in a 
coinsurance amount of $54.06. 
 
You have been asked to pay a $54.06 coinsurance for an out-of-network portion of an outpatient procedure. An 
out-of-network portion of an outpatient procedure falls within the Out-Of-Network Surgical Services 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 coinsurance for an out-of-network portion of an 
outpatient procedure provided on March 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services provided on March 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for pathology services. You say that the patient does not go there to your laboratory, 
so he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to 
process. 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 also 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 pathology services provided on March 18, 2022, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
February 14, 2022. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you saw your PCP and should 
not have a specialist copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $35 
copayment for each in-person specialist visit.  
 
The file shows that the Plan verified the provider was no longer credentialed as a PCP at the time of services. 
Therefore, you have been asked to pay a $35 copayment for the specialist visit. The specialist visit falls within 
the Physician/Practitioner Services, Including Doctor's Office Visits 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 a specialist office visit provided on February 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing services provided on March 15, 2022. 
 
You asked the Plan to pay for the services provided. You say that the testing was necessary for the 
management of the enrollee's advance cancer. The Plan denied your request. The Plan says the testing is not a 
Medicare benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records from the treating 
physician that indicates what, if any, further cancer treatment has been decided. Based on this information, we 
decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not 
have to pay for the panel testing services provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract with the dialysis 
facility to perform these labs. The Plan denied your request. The Plan says no separate payment is made for 
these labs. 
 
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 lab services provided on November 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) admission and services 
provided March 1, 2022, to March 10, 2022. 
 You asked the Plan to pay for the SNF care. You say that the SNF care should be covered. The Plan denied 
your request. The Plan says according to the records, the enrollee was in stable condition with no acute medical 
problems requiring significant management. There were no skilled services provided. 
 
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 the SNF care provided March 1, 2022, to 
March 1, 2022. Our reviewer says that the enrollee did not have daily skilled nursing needs that required the 
specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily 
skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional 
therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. There is no evidence that the enrollee required or received skilled 
services during this period. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) admission and services provided March 1, 2022, to March 10, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not require full time access to a doctor or 
specialized equipment. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be stable and improving and should only require short-term additional acute care services that can be 
administered safely at the current facility until appropriate for a lower level of care. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services (97140) provided January 13, 2022. 
 
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says insufficient information was provided. 
 
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. Insufficient clinical documentation was provided to support the billed 
service. The plan requested additional information and none was provided. Based on this information, we 
decided that there is insufficient information in the record to determine if Medicare rules for coverage of 
therapy services (97140) provided January 13, 2022. have been met. Therefore, we decided that the Plan does 
not have to pay for therapy services (97140) provided January 13, 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 October 14, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your lab does not have a 
contract with the dialysis facility for payment of these lab services. 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 October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous glucose monitor (CGM) supplies rendered on 
April 25, 2022.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable and improving and should only require short-
term additional acute care services that can be administered safely at the current facility until more stable and 
appropriate for a lower level of care. There are no services at the LTACH that the enrollee requires that are not 
already available and covered at the current facility. Transfer to LTACH is not medically necessary at this time 
as it would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiologic examination (X-ray) of the 
lower and sacral spine provided on March 18, 2022. 
 
You asked the Plan to waive the copayment for the X-ray. You say that you visited your primary care physician 
and paid a copay. He sent you to get an X-ray. Now you say you are being charged a second copay for one date 
of service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $50 
copayment for X-rays at an outpatient hospital.  
 
You have been asked to pay a $50 copayment for an X-ray at an outpatient hospital. The X-ray 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 the radiologic examination (X-ray) of the lower and sacral spine provided on 
March 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
January 14, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 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. 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. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service. 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81413 and 81414 are column II codes to column I code 81439 with a modifier indicator of 0. The column II 
codes are therefore not payable. The remaining codes at issue were requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. 
 
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 laboratory services provided on October 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital care provided from March 27, 2021, 
to April 4, 2021, billed with Diagnosis Related Group (DRG) 193. 
 
You asked the Plan to pre-approve inpatient care as billed with DRG 193. You say that these services were 
medically necessary and are supported in the record. The Plan denied your request. The Plan says DRG 193 is not appropriate as the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical record. 
The Plan argues that DRG 194 is more appropriate in this case. 
 
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. 
 
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 inpatient care as billed with DRG 193. 
Our reviewer says that the diagnosis of metabolic encephalopathy (G93.41) is not supported in the medical 
record for this inpatient admission. Our physician reviewer found that the enrollee with a history of chronic 
obstructive pulmonary disease, bipolar disorder and gastroesophageal reflux disease presented to the 
emergency department on March 27, 2021, with left-sided chest pain and dyspnea. The evaluation revealed 
computed tomography (CT) evidence of lower left lobe pneumonia with a pleural effusion. Intravenous (IV) 
antibiotics were started, and the enrollee was admitted with pneumonia. There was no evidence of metabolic 
encephalopathy during the admission. The review has determined that the medical records did not support the 
billing of metabolic encephalopathy (G93.41). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care as billed with DRG 193 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient hospital care provided from March 27, 2021, to 
April 4, 2021, billed with Diagnosis Related Group (DRG) 193.