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

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility care provided on 
July 1, 2021, to July 31, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing facility care. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost-sharing was charged 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 $184 
copayment per day for days 21 to 100 for skilled nursing facility care. This skilled nursing facility care lasted 
20 days, which days 21 to 30 of the skilled nursing facility benefit period, resulting in copayment amount of 
$3,680 ($184 per day for 20 days = $3,680). 
 
You have been asked to pay $184 copayment per day for days 21 to 100 for skilled nursing facility care. This 
item/service falls within the skilled nursing facility care 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 skilled nursing facility care provided on July 1, 2021, to July 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 9, 2022, billed with code 
81201. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
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 
June 9, 2022, billed with code 81201.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support, non-emergency 
transport, level 1 provided on September 19, 2022. 
 
You asked the Plan to pay for the ambulance service, advanced life support, non-emergency transport, level 1. 
You say that you have submitted medical records proving the medical necessity and these charges should be 
covered. The Plan denied your request. The Plan says there is no detailed description of the enrollee's clinical 
condition to reasonably determine that other means of transportation were contraindicated. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transport is covered to the nearest 
appropriate facility equipped to treat the patient. 
 
We looked at the file and Medicare rules. The records show that the enrollee was transported to a hospital that 
is 52 miles from the enrollees home, rather than a more local hospital that is located less than a mile from the 
enrollees home address. The records provided do not demonstrate that the enrollees condition required a 
higher level of trauma care or other specialized service that was only available at the more distant hospital. 
There was no evidence furnished which demonstrated that the hospital nearest the enrollees home did not have 
a bed available at the time the ambulance service was provided. The evidence provided supports that the 
hospital closer to the enrollees home would be an appropriate facility. Based on this information, we 
decided that Medicare rules for coverage of the ambulance service, advanced life support, non-emergency 
transport, level 1 have not been met. Therefore, we decided that the Plan does not have to pay for ambulance 
service, advanced life support, non-emergency transport, level 1 provided on September 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncolocty mRNA, gene expression profiling, sequencing, 
DCISionRT, DCIS Score test (0295U) provided August 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that DCISionRT is the only risk assessment that 
predicts radiation therapy benefit. The Plan denied your request. The Plan says the test is experimental and 
investigational. This test is not FDA approved and not an approved companion diagnostic test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. 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 oncolocty mRNA, gene expression profiling, sequencing, DCISionRT, DCIS Score test (0295U) 
provided August 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device (22869). 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that you feel the enrollee is an excellent 
candidate for this minimally invasive procedure and should have access based on medical necessity and strong 
level 1 clinical evidence supporting the efficacy and safety of this procedure. The Plan denied your request. 
The Plan says this procedure is considered experimental and investigational. There are not enough studies on 
Vertiflex Superion to show it is safe and effective. 
 
 
 
 
 
 
 
 
 
 
 
 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve surgery to place a Vertiflex Superion device (22869).
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 enrollee's acute needs have been met 
and stabilized in the acute care setting and is stable to transfer to LTACH for the continuation of care in the 
long term acute care setting. The Plan denied your request. The Plan says the enrollee's needs can be safely 
managed in the current acute care setting until deemed medically stable for transfer to a lower-level setting like 
skilled nursing facility. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you were admitted for weakness and atrial fibrillation. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in 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: 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 you are recovering at a very slow pace, not stable 
enough to walk on your own, or to return home. The Plan denied your request. The Plan says the request is not 
medically necessary. 
 
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 your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided on 
September 14, 2021, to September 21, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you are disputing the 
share cost. The Plan denied your request. The Plan says this cost sharing was charged 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $777.35 for inpatient hospital care.  
 
The enrollee has been asked to pay $777.35 for inpatient hospital services. This item/service falls within the 
inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount 
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay 
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
inpatient hospital services provided on September 14, 2021, to September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a syringe with needle (A4208), provided on August 10, 2022. 
 
You asked the Plan to pay for a syringe with needle. You say that the items were medically necessary. The Plan 
denied your request. The Plan says this item is not eligible for reimbursement. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted with a code 0 are not 
reasonable and necessary. 
 
In this case, the MUE for CPT code A4208 is 0. Based on this information, we decided that Medicare rules for 
coverage of procedure code A4208 have not been met. Therefore, we decided that the Plan does not have to 
pay for a syringe with needle (A4208), provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom silicone fluoride carriers. 
 
You asked the Plan to pre-approve the dental services. You say that the treatment is medically necessary. The 
Plan denied your request. The Plan says the dental treatment is not related to extraction prior to radiation or a 
facial fracture. Fluoride carriers are a preventive dental intervention and do not meet Medicare criteria for 
coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
custom silicone fluoride carriers.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77001 and 76937 billed for date of service 
June 4, 2022. 
 
You asked the Plan to pay for procedure codes 77001 and 76937. You say that these services were necessary 
and are supported as billed. The Plan denied your request. The Plan says these codes are add-on codes which 
have not been billed with an appropriate primary procedure. 
 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 procedure 
codes 77001 and 76937 are both add-on codes and have not been billed with an appropriate primary procedure 
code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure codes 77001 and 76937 billed for date of service June 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92310 billed for date of service August 22, 
2022. 
 
You asked the Plan to pay for procedure code 92310. You say that this service should be covered. The Plan 
denied your request. The Plan says procedure code 92310 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 92310 has a status indicator of N on the Physician Fee Schedule. This means that 
procedure code 92310 is not covered. Based on this information, we decided that Medicare rules for coverage of procedure code 92310 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 92310 billed for date of service August 22, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says you have exhausted your 100-day limit for inpatient services in a skilled 
nursing facility during your benefit period. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 21, 2022, 
through January 28, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that these services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained for 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 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 
a specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code A0425 billed for date of service June 12, 
2022. 
 
You asked the Plan to pay for the billed services. You say that this was the closest facility available. The Plan 
denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
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 A0425 was billed with 254 units, exceeding the MUE. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code A0425 billed for date of service June 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 8, 2022 to 
March 9, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you were not told that there was 
a change to NOAs. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 8, 2022 to 
March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on August 16, 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 payment is included in the global surgical package. 
 
The Plan must follow Medicare rules. The rules say that intraoperative services are included in the global 
surgical package. 
 
We looked at the file and Medicare rules. Procedure code 99233 was related to and billed on the same day as 
minor surgical procedure 37191. Payment for code 99233 is included in the global surgical package. Therefore, 
we decided that the Plan does not have to pay for the subsequent hospital care rendered on August 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee received oral medications and insulin. She has stable vital signs. She 
received physical and occupational therapy and needs stand-by assist with functional mobility, including gait to 
70 feet. She needs varied assistance with activities of daily living. She has no skilled nursing needs. She has 
skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee 
does not require the necessary services on an inpatient basis at the SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.