Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for private duty nursing care (S9124) provided on November 8 
to December 4, 2021. 
 
You asked the Plan to pay for private duty nursing care. You say that the Plan has denied based on a clerical 
error. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover private duty nursing services. However, the Plan offers a private duty 
nursing benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
The Plan covers up to $5,000 for private duty nursing services per year.  
We looked at the file, the Plan contract, and Medicare rules. In this case, the case record documents that the 
Plan has paid out the maximum annual benefit for private duty nursing services for 2021. Based on this 
information, we decided that the Plan's rules for coverage of private duty nursing care have not been met. 
Therefore, we decided that the Plan does not have to pay for private duty nursing care (S9124) provided on 
November 8 to December 4, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve laboratory services provided to the enrollee on July 16, 2021. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says that this procedure is unlikely to impact therapeutic decision-making in the clinical 
management of the patient. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has a gastric malignancy. The results demonstrated abnormal low level clones with 
PDGFRB, PIM1 (5 mutations), SETBP1, FANCE, and ATR mutations These abnormalities suggests 
aggressive lymphoma DNA in circulation with high tumor load. The review has determined that the enrollee 
met the coverage criteria for this testing. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve laboratory services provided to the enrollee on July 16, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from 
March 1, 2021, through April 6, 2021, from a provider not certified with Medicare. 
 
You asked the Plan to pay for inpatient mental health care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the provider is not certified with Medicare. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of inpatient mental health care have not been met. In order for a 
facility to receive reimbursement for a Medicare enrollee, the facility must be enrolled to participate in the Medicare program. We found no evidence that the provider is enrolled to participate in the Medicare program. 
The information sent by the provider is not evidence of Medicare participation. Therefore, we decided that the 
Plan does not have to pay for inpatient mental health care provided to the enrollee from March 1, 2021, through 
April 6, 2021, from a provider not certified with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553). 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. The delivery ticket does not show the specific supplies delivered. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a continuous glucose monitor (K0553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for TERT promoter testing (81345) provided July 20, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that please process and pay the underpaid 
balance of $1,113.75. The Plan denied your request. The Plan says the records do not support the billed 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 81345 
is a column II code to column I code 0089U. 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 TERT promoter testing (81345) provided July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the wheelchair lift purchased on October 
12, 2021. 
 
You asked the Plan to provide reimbursement for the wheelchair lift. You say that there are four steps to enter 
your daughter's home without room for a wheelchair ramp. Your daughter is not able to lift you up the stairs in 
your wheelchair. You feel the Plan should cover this so you can keep living in this location. The Plan denied 
your request. The Plan says this is a noncovered home improvement. Medicare does not cover this type of 
device. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to provide reimbursement for the wheelchair lift purchased on October 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided by an out-of-network 
provider on November 25, 2021. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you would like the Plan to pay for this. 
The Plan denied your request. The Plan says medically necessity could not be proven. 
 
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 an inpatient hospital stay provided by 
an out-of-network provider on November 25, 2021 have been met.  
 Medical records were never provided to verify that the services provided were medically necessary. Therefore, 
we decided that the Plan does not have to pay for an inpatient hospital stay provided by an out-of-network 
provider on November 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81263, 81450, G0452) 
provided on October 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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. CPT code(s): 81263, 
81450, and G0452, remain not supported. The place of service on the CMS-1500 form line 24B must reflect the 
location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory 
specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results 
submitted indicate the specimen was collected on October 25, 2021, and received by the lab on October 26, 
2021. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 
81263, 81450, G0452) provided on October 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel these services are needed. The Plan denied 
your request. The Plan says the denial of authorization for IRF care is correct. 
 
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 the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need 
physical and/or occupational therapy, there is no documented need for an intensive rehabilitation program. 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance miles beyond the closest facility provided to the 
enrollee on September 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this code cannot be paid for. 
 
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 A0888 is "Noncovered ambulance mileage, per mile 
(e.g., for miles traveled beyond closest appropriate facility)." 
 
We find that procedure code A0888 is not supported in the medical record. Specifically, this code explicitly 
represents non-covered mileage. Ambulance mileage is only covered to the closest reasonable facility. 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 ambulance miles beyond the closest facility provided to the 
enrollee on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT and xF genetic testing panels provided on 
June 22, 2021. 
 
You asked the Plan to pay for the gene panels. You say that this is medically necessary testing. The Plan denied 
your request. The Plan says this needs to be billed with one single code, and the POS code should be reported 
as where the sample was taken. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the gene panels have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the Tempus xT and xF genetic testing panels provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for angiography services (procedure code 75710) provided to the enrollee 
on September 27, 2021. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that procedure code 75710 is not supported by the medical records submitted. 
 
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 75710 is "Angiography, extremity, unilateral, radiological supervision and interpretation." 
 
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 supported by the medical records. Our reviewer found the records show that there is description 
of selective catheterization of the brachial and radial artery of the upper extremity in the report of the 
fistulagram of 9/27/21. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
angiography services (procedure code 75710) provided to the enrollee on September 27, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one. 
 
You asked the Plan to pre-approve Gel-one. 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. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-one. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76857 billed for date of service January 20, 
2021. 
 You asked the Plan to pay for procedure code 76857. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76857 is bundled into payment for 
code 76775. 
 
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 76857 
is a column II code to column I code 76775. 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 procedure code 76857 billed for date of service January 20, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 18, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service January 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a multianalyte assay with algorithmic analysis provided to 
the enrollee on October 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there is no data showing that the testing will, or is reasonably expected to, reduce or ameliorate 
the physical, mental, or developmental effects of an illness, condition, injury or disability. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the clinical documentation is insufficient to demonstrate a decision impact of the DecisionDx-SCC gene 
expression testing in this case. The enrollee has a diagnosis of moderately to poorly-differentiated squamous 
cell carcinoma. The case file contains a dermatopathology report,a DecisionDx-SCC requisition form, the 
results of DecisionDx-SCC testing, and a letter from the provider. 
 
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 pay for a multianalyte assay with algorithmic analysis provided to the enrollee on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve epidural steroid injections. 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 epidural steroid injection (ESI) will be 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 epidural steroid injections. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the 
records showed that you have not been compliant with medications for conservative treatment of pain. In 
addition, there is no documentation of involvement with physical therapy nor the compliance with a home 
exercise program. The review has determined that you do not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to make additional payment for the eyeglasses purchased on December 
27, 2021. 
 You asked the Plan to make additional payment for the eyeglasses. You say that you are not sure why this 
denial was issued. The Plan denied your request. The Plan says the claim for this eyewear processed correctly, 
denying only the charge beyond the allowance. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $250 per year for routine eyewear. 
 
We looked at the file and the Plan's rules. The file shows that the $250 allowance was applied to this claim. The 
denial was issued due to the amount beyond the $250 allowance which cannot be paid. Therefore, we decided 
that the Plan does not have to make additional payment for the eyeglasses purchased on December 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 22, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0480 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on July 22, 2021.