Persius/hicric huggingface dataset:
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 an admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says your needs can be met at a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
January 17, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services provided by an out-of-network provider on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (12011) provided on October 7, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 12011 is a column II code to column I code 21310. 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 services (12011) provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99310) provided on December 28, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the services (99310) provided on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and standard 
supplies (K0553, K0554). 
 
You asked the Plan to pre-approve a CGM and standard supplies. You say that the requested items should be 
covered because you are legally blind and using your current equipment to check your blood sugar is difficult. 
The Plan denied your request. The Plan says you do not meet criteria for the requested item. 
 
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 indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM and 
standard supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) and standard supplies (K0553, K0554).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 20, 
2022. 
 
You asked the Plan to pay for procedure code 99285. You say that this claim was underpaid. The Plan denied 
your request. The Plan says Procedure code 99285 was not supported, so the reimbursement was downgraded 
to 99284. 
 
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 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high complexity. Counseling and/or coordination of care with 
other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function. 
 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 procedure code 99285. Our reviewer says that procedure 
code 99285 was not supported by the medical record. Our reviewer found the patient is a 77-year-old female 
with diarrhea and abdominal pain with small amount of blood on toilet paper. She presented to the emergency 
room with stable vitals and no report of chest pain or dyspnea. Her white blood cell count was 11 and she had 
heme-negative brown stool. Her abdominal exam was benign. Computed Tomography showed no obstruction. 
She was diagnosed and treated with colitis. Procedure code 99285 was submitted but not supported as there 
was not high complexity or severity of the case documented. The patient had colitis, but vitals were stable 
throughout the emergency stay, and the patient responded to treatment. Based on the documentation, the more 
appropriate code would be 99284.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99285 billed for date of service February 20, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 7, 2022 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith. The Plan denied your request. The Plan says  
 
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 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 nursing facility care provided on January 7, 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 Vitamin D testing provided on October 15, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the code is not 
a Medicare benefit for the diagnosis listed. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. The claim does not include a covered diagnosis for the testing at issue. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the Vitamin D testing provided on October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anesthesia for Procedures on the Neck provided on October 
28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Anesthesia for Procedures on the Neck. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says this code is ineligible for payment. 
 
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 Anesthesia for Procedures on the Neck provided 
on October 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for nursing facility care (99308) provided on January 10, 2022. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary, The Plan denied 
your request. The Plan says that this is not covered out-of-network. 
 
The Plan must follow Medicare rules. 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.  The Plan contract states that because the plan has a Point-of-Service (POS) option, care enrollees 
receive from an out-of-network provider for certain services may be covered. Prior authorization is not required 
for covered services received out-of-network.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided any information supporting that these services are not 
covered under the POS benefit. Therefore, we decided that the Plan has to pay for nursing facility care (99308) 
provided on January 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 24, 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 billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray provided on December 3, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an X-Ray. You say that you would like to request reconsideration of the denied 
claim. 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 an X-Ray provided on December 3, 2021 by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glasses provided on November 23, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the glasses. You say that you were unaware and never told you could not buy 
glasses from an out-of-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 glasses provided on November 23, 2021, by an 
out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray provided on January 26, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an X-Ray. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the member's plan excludes coverage for this OON service. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an X-Ray provided on January 26, 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 anesthesia supplies (99072, A4550) provided to the enrollee 
on November 11, 2021. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says there is minimal to no documentation submitted to verify if the services were medically 
necessary. 
 
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 procedure codes A4550 and 99072 have a status indicator of B on the Physician Fee Schedule. This means that these codes are not separately payable. Based on this information, we decided that Medicare 
rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia supplies (99072, A4550) provided to the enrollee on November 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transthoracic echocardiogram (TEE). 
 You asked the Plan to pre-approve TEE. You say that the services are necessary. The Plan denied your request. 
The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that coverage for TEE is considered medically reasonable 
and necessary 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 pre-approve TEE. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found clinical guidelines do not support carrying 
out a TEE in this setting. In summary, there is no supportive evidence for the medical necessity of a TEE in this 
this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of TEE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiogram (TEE).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223), and subsequent hospital care 
(99232, 99233) provided from May 5, 2021, to May 8, 2021. 
 
You asked the Plan to pay for the hospital care. You say that the enrollee was not enrolled in hospice on the 
date of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the initial hospital care (99223), and subsequent hospital care 
(99232, 99233) provided from May 5, 2021, to May 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test (0037U) provided 
December 3, 2021. You asked the Plan to pay for the laboratory service. 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 service have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) test 
(0037U) provided December 3, 2021.
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 you appear to be stabilizing and should only require short-term additional acute care 
services that can be safely completed at the current facility until more stable and appropriate for a lower level 
of care. There are no services at the LTACH that you require that are not already available and covered at the 
current facility. Transfer to the LTACH is not medically necessary 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.