Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you feel the enrollee meets Medicare 
criteria for acute inpatient long-term acute care that cannot be accomplished at a lower level of care. The Plan 
denied your request. The Plan says based on Medicare guidelines and the information we have about the 
enrollee's condition they do not meet all the requirements. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted for encephalopathy and acute hypoxic respiratory failure 
due to COVID-19 pneumonia. The record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee is receiving appropriate care at the present 
setting. The enrollee does not require services at the LTACH that are not available at the acute care hospital 
where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee has tried conservative interventions. The 
Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Botox. Our physician reviewer found 
that the enrollee has a diagnosis of overactive bladder. The record indicates that the enrollee has not attempted 
anticholinergic medications. The record does not indicate that the enrollee is refractory to, had inadequate 
response to, or are intolerant of an anticholinergic medication. The FDA has not stated that the requested drug 
is indicated for the enrollee's condition. The Medicare approved  drug compendia do not contain a supportive 
citation for the use of the requested drug in the enrollee's clinical situation. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on March 31, 2022. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you want the Plan 
to pay for these services. The Plan denied your request. The Plan says the Plan covers ambulance transportation 
only when you are transported by ambulance. Since you were not transported by this ambulance, the 
service is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 31, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Next-Generation Sequence (NGS) testing panel 
provided on July 2, 2021. 
 
You asked the Plan to pre-approve the NGS testing panel. You say that the molecular testing was requested 
directly from the treating physician who makes the professional determination of diagnosis and medical 
necessity to successfully treat the patient. You say that Medicare has determined that Next-Generation 
Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally. You say 
that the treatment the enrollee received was medically necessary. The Plan denied your request. The Plan says 
the requested test is statutorily excluded from coverage by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
statutorily excluded from coverage.   
We looked at the file and Medicare rules. The records show that the gene panel that is in dispute included 
testing for the FANCC gene. Based on this information, we decided that Medicare rules for coverage of the 
NGS testing panel have not been met. Therefore, we decided that the Plan does not have to pre-approve Next-
Generation Sequence (NGS) testing panel provided on July 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiologic examination of the chest provided on  
September 28, 2020. 
 
You asked the Plan to pay for the radiologic examination of the chest. The Plan denied your request. The Plan 
says Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 
calendar year from the date the services were furnished. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the radiologic examination of the chest was not filed until May 19, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for a radiologic examination of the chest provided on 
September 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compressor, segmental home model 
without calibrated gradient pressure (E0651) and a segmental pneumatic appliance for use with pneumatic 
compressor, full leg (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compressor device and appliance. You say that this appeal 
process has caused unnecessary delay in the enrollee receiving treatment. In order to provide the enrollee with 
the best care 
possible, a GAP exception is requested as well as the reconsideration of his eligibility of the durable medical 
equipment. The Plan denied your request. The Plan says the enrollee must use network providers to get his 
medical care and services. There are in-network provider(s) within a reasonable distance from his location that 
can provide this service or item. 
 
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 pneumatic compressor, segmental home model without calibrated gradient pressure (E0651) and a segmental 
pneumatic appliance for use with pneumatic compressor, full leg (E0667) 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 pay for the therapeutic procedure coded 97110 provided on 
November 24, 2021. 
 
You asked the Plan to pay for the therapeutic procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 
 We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows 
that the services were performed by a physical therapist assistant in a home health or hospice setting. This 
means there is a more appropriate code to be billed for the services rendered. Based on this information, we 
decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on November 
24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin injection (J1815) provided on April 29, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the self-administered drug is 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 drug provided is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin injection (J1815) 
provided on April 29, 2022.  
 Benefits for this item 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 domiciliary or rest home visit and debridement of nails 
provided on January 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit and debridement of nails. You say that the 
enrollee is a resident in a nursing home and has an authorization on file for all care at the facility including 
consultations. The Plan denied your request. The Plan says services from non-participating providers are not 
covered unless preauthorized. 
 
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 domiciliary or rest home visit and debridement 
of nails provided on January 24, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect test (0012M) provided February 1, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you believe that the evidence supporting the 
use of Cxbladder detect as a medically necessary diagnostic service is well established. The Plan denied your 
request. The Plan says this service is considered experimental and unproven. 
 
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. Cxbladder Detect (0012M) is not an approved test with Palmetto 
GBA and has not been evaluated by the MolDx Programs technical assessment process. 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 Cxbladder Detect test (0012M) provided February 
1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCR testing provided on April 22, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says more than 5 targets were 
tested. 
 
The Plan must follow Medicare rules. Medicare rules say that Multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered.  
 
We looked at the file and Medicare rules. The documentation shows that 6 or more pathogens were tested in 
the requested panel. Based on this information, we decided that Medicare rules for coverage of the testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the PCR testing provided on April 
22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from April 19, 2022, 
through May 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physical therapy services. You say that the services were necessary, and you 
were not aware that the provider was out-of-network. The Plan denied your request. The Plan says services 
received out-of-network are not covered. 
 
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 physical therapy services provided from April 19, 
2022, through May 20, 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 surgical services rendered on March 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 procedure code 45384 is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the records do not show that procedure code 45384 was performed as a separate and 
distinct procedural service from billed codes 45385. Based on this information, we decided that Medicare rules 
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does 
not have to pay for the surgical services rendered on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for PrismRA services provided on April 13, 2022. 
 
You asked the Plan to pay for the PrismRA services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that testing must be FDA approved. 
 
We looked at the file and Medicare rules. Review of the file shows that the PrismRA testing at issue in this 
appeal is not FDA approved. Based on this information, we decided that Medicare rules for coverage of the 
PrismRA services have not been met. Therefore, we decided that the Plan does not have to pay for PrismRA 
services provided on April 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81227, 81230, 81231, 81232, 81238, 81291, 81306, 0031U, 0032U, 0033U, 81328, 81335, 81406 and 
81407. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare rules. 
 
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 
March 8, 2022, billed with codes 81227, 81230, 81231, 81232, 81238, 81291, 81306, 0031U, 0032U, 0033U, 
81328, 81335, 81406 and 81407.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the health club membership purchased for the year 2021, up to the 
Plans $150 Wellness Allowance. 
 
You asked the Plan to pay for the health club membership. You say that your health club used a shortened 
version of your name. The Plan denied your request. The Plan says that the proof of payment submitted does 
not match your name. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
up to $150 per calendar year. 
 
The Plans rules for the enrollee has submitted a valid request for reimbursement for a health club membership 
along with proof of payment. Therefore, we decided that the Plan has to pay for the health club membership 
purchased for the year 2021, up to the Plans $150 Wellness Allowance.  
 
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 pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of LTACH 
admission. The Plan denied your request. The Plan says the enrollee's medical record shows they do not meet 
the Medicare guidelines for admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with acute on chronic respiratory failure in the setting of 
COVID-19 pneumonia. The record indicates that the enrollee has not completed the acute treatment phase and 
still requires acute care services before transitioning to a lower level of care. The medical record does not 
indicate that the enrollee requires services that they are not currently receiving but that would be available at 
the LTACH facility. 
 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
March 18, 2019 and March 20, 2019. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services are not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until April 5, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on March 18, 2019 and 
March 20, 2019.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health occupational therapy visits (CPT code 
G0152 x2) and the home health physical therapy visits (G0151 x3). 
 
You asked the Plan to pre-approve the home health services. You say that the home health services are 
necessary. The Plan denied your request. The Plan says the enrollee was enrolled in a federal Medicare-
certified Hospice Program. 
 
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 is currently under the Medicare hospice benefit. Therefore, we decided that the Plan does not have 
to pre-approve home health occupational therapy visits (CPT code G0152 x2) and the home health physical 
therapy visits (G0151 x3).