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

 
We decided that the Plan does not have to pay for genetic testing billed for date of service August 3, 2021. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were billed correctly. The Plan 
denied your request. The Plan says documentation to support the services at issue was not 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. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of genetic testing billed for date of 
service August 3, 2021. have been met. Specifically, medical records and the testing results are not available to corroborate the services billed. Therefore, we decided that the Plan does not have to pay for genetic testing 
billed for date of service August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for gas related to a transplant (S9975) purchased from 
May 30, 2022, to May 31, 2022. 
 
You asked the Plan to reimburse you for the gas. You say that you would like to be reimbursed for your 
lodging stay and travel expenses. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gas have not been met. Specifically, the file shows that the Plan reimbursed you for lodging 
and mileage at the Medicare rate. Gas is not a reimbursable expense. Therefore, we decided that the Plan does 
not have to reimburse you for gas related to a transplant (S9975) purchased from May 30, 2022, to May 31, 
2022.
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 October 23, 2020, to October 31, 2020. 
 
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 provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 the documentation provided does 
not support that the enrollee received parenteral/IV feeding during the 7 day period at issue in this case. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from October 23, 2020, to 
October 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 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 the enrollee does not meet the Medicare coverage criteria for an IRF admission. 
 
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 the enrollees nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee 
will be willing to fully participate in and benefit from the intensive rehabilitation therapy program provided in 
an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with ongoing safety 
concerns and a potential for functional improvement however, the documentation does not support that she 
would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that the 
enrollee would require skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, 
under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional status.  
The enrollee can receive further services at a lower level of 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are an in-network provider with the Plan and no 
authorization should be needed. 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 an office visit provided on May 27, 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 laboratory services provided on April 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you disagree with the Plan's 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 the laboratory services are not supported in the medical record. Specifically, these services were 
billed with a primary diagnosis of D75.81 (myelofibrosis). This diagnosis code is a manifestation code. This 
means that this code cannot be used as a primary diagnosis code. 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 laboratory services provided on April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an Omalizumab injection provided on 
February 17, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were told your insurance 
would act as a supplement to cover what Medicare did not. 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 20% 
coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs.  
 
You have been asked to pay $329.06 for an injection which is 20% of the allowed amount ($1,645.28 allowed 
amount x 20% coinsurance = $329.06). An injection falls within the Medicare Part B Prescription Drugs 
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 Omalizumab injection 
provided on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility requested 
on June 16, 2022. 
 
You asked the Plan to pre-approve the requested inpatient psychiatric admission. You say that it is felt that this 
level of care is needed and should be approved. The Plan denied your request. The Plan says the facility does 
not provide inpatient psychiatric care as defined by Medicare. The enrollee also does not require this level of 
care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested inpatient psychiatric 
admission. Our reviewer says that the records do not support the medical necessity of psychiatric care in the 
inpatient setting at the time it was requested. Our physician reviewer found This 42-year-old male was 
involuntarily admitted to the acute inpatient psychiatric hospitalization on June 14, 2022, with Schizoaffective 
Disorder, Bipolar Type and Obsessive-Compulsive Disorder. Based upon review the records provided it was 
not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to 
self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance 
including delusions, auditory or visual hallucinations. The health plans denial of inpatient psychiatric services 
appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a 
danger to himself or others and was cooperative and compliant. It did not appear that active treatment was 
taking place. It did not appear that the services were reasonably expected to improve the patients condition or 
for the purpose of diagnosis. He is noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested inpatient psychiatric admission have not been met. Therefore, we 
decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility requested on 
June 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 7, 2022 billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be covered based on Medicare 
guidelines. The Plan denied your request. The Plan says this claim represents apparent unbundling. 
 
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. 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 
April 7, 2022 billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient surgery to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve outpatient surgery. You say that your surgical center is in-network but does 
not do general anesthesia. You say that you do not perform this procedure at any location other than the 
hospital due to the nature of anesthesia. The Plan denied your request. The Plan says there are nine in-network 
facilities within 50 miles from the enrollee's address that could meet the specific medical needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
outpatient surgery to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a nuclear medicine study, a Regadenoson 
injection, or Technetium Tc-99m tetrofosmin. 
 
You asked the Plan to waive the cost share for a nuclear medicine study, a Regadenoson injection, and 
Technetium Tc-99m tetrofosmin. You say that you should not be responsible to pay this because your doctor 
did not consider you a good candidate for a treadmill test. The Plan denied your request. The Plan says the cost 
share was applied correctly. 
 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 $130 
copayment for in-network Medicare-covered radiological diagnostic services, not including x-rays performed 
in a physician's office or at a free-standing facility. Your contract with the plan also clearly says that you must 
pay a $0 copayment for Medicare-covered Part B allergy antigens and a 20% coinsurance for all other 
Medicare-covered Part B drugs when received from an in-network provider. 
 
You have been asked to pay $223.47 for a nuclear medicine study, a Regadenoson injection, and Technetium 
Tc-99m tetrofosmin. A nuclear medicine study falls within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. A Regadenoson injection, and Technetium Tc-99m tetrofosmin fall 
within the Medicare Part B Prescription Drugs 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 
cost share for a nuclear medicine study, a Regadenoson injection, and Technetium Tc-99m tetrofosmin.  
 
 
 
Date of 
Service 
Service/CPT Amount 
Billed 
Plan 
Allowance 
Cost Share 
April 8, 2022 78452 $728.66 $310.74 $130.00 
April 8, 2022 J2785 $280.00 $245.16 $ 49.03 
April 8, 2022 A9502 $280.00 $222.20 $ 44.44 
Total  $1288.66 $778.10 $223.47
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve excess skin removal of the arm. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this request is considered cosmetic, as there is no documentation that indicates that the 
surgery will correct congenital defects, developmental abnormalities, trauma, infections, tumors, or disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that in this case, the record indicates that the enrollee has had weight loss and has excess skin on the arm. 
The record provided does not document that there are functional impairments or the presence of medical 
complications not treatable by conservative therapy. The records do not indicate that this is a reconstructive 
procedure due to cancer treatment or sequelae. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage 
criteria are not satisfied. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve excess skin removal of the arm.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from April 28, 2022, 
through April 29, 2022. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under your contractual 
policy or 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 provided are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from April 28, 2022, through April 29, 2022.   
Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home health visit. You say that it is the facilities responsibility to obtain prior 
authorization and you would like the claim reprocessed. 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. 
 
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 home health visit provided on April 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 the duplex scan of extremity veins (93971) provided on 
March 14, 2022. 
 
You asked the Plan to pay for the duplex scan of extremity veins. You say that you would like this claim to be 
processed. The Plan denied your request. The Plan says despite multiple outreaches by the Health Plan, this 
provider has not submitted any clinical records to support the medical necessity of the service(s). The Plan also 
says that the service remains denied based upon Medicare guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the duplex scan of extremity veins 
(93971) provided on March 14, 2022. have been met. Medical records were not provided with this case. The 
record shows that the Plan made multiple attempts to request records, but they were not provided. Without this 
information, we cannot determine if the provided service was medically necessary. Therefore, we decided that 
the Plan does not have to pay for the duplex scan of extremity veins (93971) provided on March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says this 
request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.