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

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 16, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that the services should be paid. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth services provided on June 14, 
2022. 
 
You asked the Plan to waive the copayment for telehealth services. You say that you don't understand the 
phone visit so you feel you shouldn't pay a copayment. 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 a $20 
copayment for physician/practitioner services/telehealth services.  
 
You have been asked to pay a $20 copayment for telehealth services. This item/service falls within the 
physician/practitioner services/telehealth services 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 telehealth services provided on June 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of head or brain (70450) 
provided on October 19, 2021. 
 
You asked the Plan to pay for the CT. You say that the enrollee was no longer enrollee in hospice on the date 
of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 18, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the computed 
tomography (CT) of head or brain (70450) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued injections, Keytruda 400 mg (J9271). 
 
You asked the Plan to pre-approve continued injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says the enrollee does meet medical necessity and criteria for the 
requested continued therapy with Keytruda. 
 
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 continued injections. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found guidelines support 2 years of immunotherapy for treatment of both metastatic on-
small cell lung cancer and metastatic urothelial cancer. This enrollee had ablation of an oliogometastases in 
4/2021. Recent scans show stable disease. A review of the literature does not support a duration of continuing 
pembrolizumab for oligoprogression for 2 years. The service is not reasonable or 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 continued injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued injections, Keytruda 400 mg (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on 
May 6, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on May 
6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria. 
 
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. The file shows that pharmacogenetics and cardiogenetic testing was 
provided. The records from the enrollees treating physician do not show that the testing was ordered for a 
specific medical problem. The records do not show that the pharmacogenetic testing was ordered based on a 
known gene-drug interaction or other clinical factors. The testing at issue is not covered for screening services. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing provided on May 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 97116, 97530, 97110, 97112, and 97535 provided 
from March 1, 2022, to March 9, 2022. 
 
You asked the Plan to pay for codes 97116, 97530, 97110, 97112, and 97535. You say that you disagree with 
the Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
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 codes 97116, 97530, 97110, 97112, and 97535 are not supported in the medical record. 
Specifically, no medical records were provided for the dates of service at issue. Based on this information, we 
decided that Medicare rules for coverage of codes 97116, 97530, 97110, 97112, and 97535 have not been met. 
Therefore, we decided that the Plan does not have to pay for codes 97116, 97530, 97110, 97112, and 97535 
provided from March 1, 2022, to March 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has left-sided hemiparesis 
from a stroke in 2018. He has tried physical and occupational therapy, static bracing, and electrical stimulation. 
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert 
opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is 
insufficient evidence in the literature that this device will increase participation in bimanual activities. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) or waive the 
copayment for the exam provided on July 20, 2022. 
 
You asked the Plan to pay for the determination of refractive state and to waive the copayment for the exam. 
The Plan denied your request. The Plan says your provider states the charges were billed with a medical 
diagnosis for the eye refraction. The Plan also says that a $30.00 copay applies to medical exams. 
 
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 eye refractions when it is performed during a routine exam. 
 
 
 
 
 
 We looked at the file and the Plan's rules. Specifically, the exam provided was for a medical diagnosis of Age-
related nuclear cataract, bilateral, and not for a routine eye exam. The record also shows that you signed a 
Refraction Waiver with the provider's office, acknowledging that the refraction would not be covered. Based on 
this information, we decided that the Plan's rules for coverage of the determination of refractive state or waive 
the copayment for the exam have not been met. Therefore, we decided that the Plan does not have to pay for 
the determination of refractive state (92015) or waive the copayment for the exam provided on July 20, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on July 19, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the services were medically necessary, and you 
are appealing with supporting records. The Plan denied your request. The Plan says the enrollee must receive 
care from a network provider. 
 
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 provided on July 19, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from January 13, 2019, to January 16, 2019, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you believe that the documentation supports payment for the services as they were originally billed with diagnosis N17.0 resulting in diagnosis-related group (DRG) 073. The Plan denied your request. The Plan says that the documentation does not support payment for the hospital care as it was originally billed.
Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with principal diagnosis code, N17.0, defined as acute kidney failure with tubular necrosis. Our Medical Director states that the clinical documentation does not support DRG 073 - Cranial and peripheral nerve disorders with a major complication or comorbidity, such as acute tubular necrosis. The enrollee had a rapid response to fluid repletion. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from January 13, 2019, to January 16, 2019, at the DRG originally billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from January 13, 2019, to January 16, 2019, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx testing (0037U) provided on April 
22, 2022. 
 
You asked the Plan to pay for the FoundationOne CDx testing. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not 
include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the FoundationOne 
CDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx testing (0037U) provided on April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 CDx testing (0242U) provided on July 1, 2022. 
 
You asked the Plan to pay for Guardant360 CDx testing. You say that this testing is FDA approved and should 
be covered. The Plan denied your request. The Plan says tests not ordered by the physician who is treating the 
beneficiary are not reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory 
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. 
 
We looked at the file and Medicare rules. The Plan contacted the referring provider listed on the claim, and the 
provider advised that they did not order the genetic testing. Based on this information, we decided that 
Medicare rules for coverage of Guardant360 CDx testing have not been met. Therefore, we decided that the 
Plan does not have to pay for Guardant360 CDx testing (0242U) provided on July 1, 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the requested SNF services do not meet the 
requirements for approval. 
 
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 that the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not return to baseline level of 
independence with walker and take care of self without therapy. The Plan denied your request. The Plan says 
the request is not medically necessary, the enrollee can safely receive the services they need in other settings, 
for 
example: a skilled nursing facility. 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. There is no documented need for intensive rehabilitation services and 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 acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 8, 2021, billed 
with codes 81256, 81400, 81401, and 81403. 
 
You asked the Plan to pay for the genetic testing billed. You say that the testing was medically necessary. The 
Plan denied your request. The Plan says the codes are not separately payable. 
 
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 
December 8, 2021, billed with codes 81256, 81400, 81401, and 81403.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a home COVID-19 test purchased January 12, 2022.
You asked the Plan to pay for this test. You say that this test should be paid for by the Plan. The Plan denied
your request. The Plan says the decision to deny coverage is correct. The Plan states that the contract
addendum for coverage of COVID-19 home test kits was sent to all enrollees and indicates that coverage would
be provided beginning on January 15, 2022, unless the test was specifically ordered by a physician. A
purchased at-home COVID-19 test was not a covered benefit on January 12, 2022.
The Plan must follow Medicare rules. The rules say that plans were given the option to cover COVID-19 home
testing kits as a supplemental benefit but were not required to do so by Medicare. The Plan communicated to
enrollees that this testing would be covered as a supplemental benefit, free of charge, after January 15, 2022,
unless the testing was required prior to that date due to physician intervention. The medical records do not
show physician intervention. Furthermore, Medicare did not cover purchased or over the counter COVID-19
home testing kits until April 4, 2022. Therefore, we decided that the Plan does not have to pay for a home
COVID-19 test purchased January 12, 2022.