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

 
We decided that the Plan does not have to pay for the lab testing services provided on October 21, 2021. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement in place that the codes 
are included in the dialysis rate. The Plan denied your request. The Plan says the tests are bundled into the 
dialysis services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve a bone replacement graft for ridge preservation. You say that you need this 
procedure done and you would like the plan to reconsider the denial. The Plan denied your request. The Plan 
says the requested service is not covered under your benefit package. 
 
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 a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft, retained natural tooth 
(D4263), guided tissue regeneration (D4266), gingival flap procedure, including root planing (D4241) and a 
bone replacement graft for ridge preservation (D7953). 
 
You asked the Plan to pre-approve dental services. You say that you have been with the plan for years and you 
would like the plan to reconsider the denial and approve the requested services. The Plan denied your request. 
The Plan says the requested services are not a covered benefit with your Plan. 
 
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 a 
bone replacement graft, retained natural tooth (D4263), guided tissue regeneration (D4266), gingival flap 
procedure, including root planing (D4241) and a bone replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF admission. You say that the member is no capable of caring for herself 
and she needs rehab. The Plan denied your request. The Plan says SNF admission is 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found The member has stabilized medically 
and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled 
therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level 
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member 
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is 
medically stable without any acute exacerbations of chronic medical problems.  Her physical function is at or 
near her baseline and she can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services is not medically necessary. 
 
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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease (bacterial or viral respiratory tract 
infection), pathogen-specific nucleic acid panel for 22 targets provided on November 6, 2021. 
 
You asked the Plan to pay for the 22-target respiratory pathogen panel. You say that this should be covered. 
The Plan denied your request. The Plan says panels must be billed with a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that panels testing for more than 5 pathogens are not 
considered reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 22-target respiratory pathogen panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the infectious disease (bacterial or viral respiratory tract infection), pathogen-specific 
nucleic acid panel for 22 targets provided on November 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare SNF requirements. 
 
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 services. Our reviewer says that 
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing 
perspective, you received oral medications. You had stable vital signs. You underwent paracentesis. Regarding 
rehabilitation services, you received physical therapy. You were at a supervision to contact guard/minimal 
assist level for functional mobility including gait to 75 feet. There are no identifiable skilled nursing service 
needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy 
services on a daily basis. As a practical matter, you do not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility SNF services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery services provided on July 8, 2020. 
 
You asked the Plan to pay for the services provided. You say that the documentation supports the billing. The 
Plan denied your request. The Plan says the code is not supported in 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 29824 is Arthroscopy, shoulder, surgical; distal 
claviculectomy including distal articular surface (Mumford procedure).  
 
 
 
 We find that CPT code 29824 is not supported in the medical record. A resectioning of the distal clavicle was 
not described in the provided records for the billed code. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the surgery services provided on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the tests are included in the dialysis rate. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the viral testing provided on July 20, 2021. 
 
You asked the Plan to pay for the testing. You say that this was correctly billed with POS code 81 for an 
independent laboratory. The testing is not performed in a physician's office. The Plan denied your request. The 
Plan says the POS code must match the location at which the sample was collected. 
 
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 testing 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 viral testing provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertical platform wheelchair lift. 
 
You asked the Plan to pre-approve a Vertical platform wheelchair lift. You say that the wheelchair lift is 
necessary as you are wheelchair bound and your mother is having difficulties moving you into the house. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that wheelchair lifts are not covered 
because they are not primarily medical in nature.  
 
While a wheelchair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a Vertical platform wheelchair lift.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on July 13, 2021. 
 
You asked the Plan to pay for the air ambulance services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says transport via air ambulance was not medically 
necessary.  
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that air ambulance was not medically necessary for this patient. Our physician reviewer found the patient 
suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The 
patient has a non-ST elevation myocardial infarction and required ambulance transportation. 
The documentation does not support that the patient's condition was such that the time needed to transport a 
patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or 
seriously endangered the patient's health. The patient was admitted on 11:43 PM. He was treated with aspirin 
and nitroglycerin and chest pain was relieved. He was hemodynamically stable at the time of air ambulance 
transport at 8:34 AM the following day. The documentation supports that the transferring hospital did not have 
adequate facilities to provide the medical services needed by the patient. Transfer to the accepting facility was 
medically necessary but did not require air ambulance transport as the patient was hemodynamically stable.  
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC molecular testing service provided on 
November 9, 2021. 
 
You asked the Plan to pay for the DecisionDx-SCC molecular testing service. You say that this testing should 
be covered based on the medical documentation provided. The Plan denied your request. The Plan says there is 
no data showing testing will reduce or ameliorate the enrollee's condition. 
 
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 DecisionDx-SCC molecular testing 
service. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee was diagnosed with T3 squamous cell cancer 
of the skin. In this case, surveillance services per the National Comprehensive Cancer Network aredictated by guidelines which do not include molecular testing. Therefore, the requested testing services the enrollee 
received will be denied as experimental/investigational. 
 
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 DecisionDx-SCC molecular testing service have not been met. Therefore, 
we decided that the Plan does not have to pay for the DecisionDx-SCC molecular testing service provided on 
November 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided on September 21, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim was originally sent to workers 
compensation in error. The Plan denied your request. The Plan says 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 inpatient hospital care was not filed until December 15, 2021. 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 inpatient hospital care provided on September 21, 2020.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have skilled nursing needs and you 
do not need skilled therapies without documentation on a daily basis in an inpatient setting. Your wound care 
needs can be met at a lower intensity level such as in an assisted living facility (ALF) with continued wound 
care and referral to a wound care clinic. 
 
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.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve heart catheterization and Ventriculography 
 
You asked the Plan to pre-approve heart catheterization and Ventriculography. You say that these services are 
medically necessary. The Plan denied your request. The Plan says the requested service is not medically 
necessary under Medicare and exceeds the patient's medical need 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve heart catheterization and 
Ventriculography. Our reviewer says that the requested heart catheterization and Ventriculography are not 
medically necessary. Our physician reviewer found the patient had a normal radionuclide stress test in March 
of 2021. She has not had chest pain. Documentation does not support the rationale for this invasive imaging 
study. Guidelines do not support a need for cardiac catheterization in this setting. As a result, at this time 
cardiac catheterization would not be considered medically appropriate and necessary in this patients 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 heart catheterization and Ventriculography have not been met. Therefore, we 
decided that the Plan does not have to pre-approve heart catheterization and Ventriculography
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71101-26 billed for date of service October 
22, 2021. 
 
You asked the Plan to pay for procedure code 71101-26. You say that this claim should be paid. The Plan 
denied your request. The Plan says this code was billed with an incorrect modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should use the technical Component 
(TC) modifier when they perform the test, but do not do the interpretation. Providers should not add a TC 
modifier when performed both the technical and professional components on the same date. In this case, you 
billed two separate claims for code 71101 for this same date of service.  Once claim had modifier TC 
appended, and one had modifier 26 (professional component) appended.  According to Medicare rules, these 
modifiers should not be used if the provider performs both the technical and professional component of a 
service.  Rather, no modifier should be appended in that scenario to show that the provider performed both 
portions of the service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 71101-26 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 71101-26 billed for date of service October 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport services provided on October 28, 2021. 
 
You asked the Plan to pay for ambulance transport services. You say that the patient was enrolled in hospice 
after the transport. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of all Medicare covered services related or unrelated to the members terminal condition. The 
Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of 
election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers 
attending physician services and all care unrelated to the terminal illness until the first day of the month 
following the month in which hospice was revoked or discharged. 
 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 ambulance transport services provided on October 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from  
October 21, 2021, through November 19, 2021. 
 You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services is 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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing 
perspective; the enrollee received topical medications. The enrollee was monitored for orthostatic hypotension. 
Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT).  
The enrollee was at an independent level for functional mobility. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable 
skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 
As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from October 21, 2021, through 
November 19, 2021.