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

 
We decided that the Plan has to pay for Tempus xF genetic testing services provided on November 9, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says that the testing that was 
ordered is supported only for the treatment of non-small cell lung cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the genetic testing services. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the per the National Comprehensive Cancer Network Guidelines: tumor/somatic gene 
profiling is recommended for patients with locally advanced/ metastatic disease who are candidates for anti-
cancer therapy to identify uncommon mutations, specifically testing for potentially actionable somatic findings 
including, but not limited to: fusions (ALK, NRG1, NTRK, ROS1, FGFR2, RET), mutations (BRAF, 
BRCA1/2, KRAS, PALB2), amplifications (HER2), microsatellite instability (MSI), and/or mismatch repair 
(MMR) deficiency.  
 Molecular profiling or next generation sequencing can help identify available therapies and identify eligibility 
for clinical trials. It is considered a standard of care. The service was reasonable and 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 the genetic testing services have been met. Therefore, we decided that the Plan 
has to pay for Tempus xF genetic testing services provided on November 9, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Sprint PNS (CPT code 64555). 
 
You asked the Plan to pre-approve the service. You say that there is no reason for it to be denied since it was 
approved in February, but you were unable to have this service done at that time and it is in order to treat your 
condition. You state that you are having trouble walking and your lower back pain has become worse. The Plan 
denied your request. The Plan says there are not enough studies to show this nerve procedure improves the 
health of patients with your problem, and the Sprint PNS device does not fit the Medicare definition of an 
implanted peripheral nerve stimulator. 
 
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 service. Our physician reviewer 
found Sprint PNS is experimental for the treatment of low back pain. More research is needed. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Sprint PNS (CPT code 64555).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five (5) fractions of stereotactic body radiation therapy 
(SBRT) using image guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested radiation therapy is medically 
necessary. The Plan denied your request. The Plan says the requested radiation therapy does not meet criteria. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found SBRT can be considered in select patients with oligometastatic metastases from 
prostate cancer. For ultracentral tumor a more protracted course of radiation (8-15 fractions) could be equally 
effective as SBRT, possibly with less risks. While SBRT could be considered to be furnished in accordance 
with accepted standards, it does not meet the LCD criteria as outline below as thoracic nodal sites are not 
included in the indications for SBRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve five (5) fractions of stereotactic body radiation therapy (SBRT) using image guided 
radiation therapy (IGRT).
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 Skilled Nursing Facility (SNF) services. You say that you feel you need that 
level of care. The Plan denied your request. The Plan says the service is not medically necessary and that you 
do not meet the criteria for continued stay at SNF. 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 Skilled Nursing Facility (SNF) services. 
Our reviewer says that the service is not medically necessary and that you do not meet the criteria for continued 
stay at SNF. Our physician reviewer found Based on the documentation provided, it is my opinion that the 
enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The 
enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and 
tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of the enrollees condition. The enrollees care needs, as a practical matter, 
can be provided at a lower level of care (ex. home, AL, LTC). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Skilled Nursing Facility (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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on December 22, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a home health visit. You say that the facility is responsible to obtain the prior 
authorization and the services were rendered in good faith. The Plan denied your request. The Plan says the 
rendering provider is an OON provider and there was no referral from an in-network provider or an approved 
authorization. Also, the service rendered was not urgent or emergent. 
 
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 home health visit provided on December 22, 
2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you an additional $250 for hearing aids provided on 
January 26, 2022. 
 
You asked the Plan to reimburse you an additional $250 for the hearing aids. The Plan denied your request. The 
Plan says per your Evidence of Coverage a 25% coinsurance, then any amount over $1,000 every 3 years is the 
members responsibility for out-of-network providers. In this case, the member received a payout of $750 after 
the 25% coinsurance of $250 was accounted for. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan processed the claim correctly. Therefore, 
we decided that the Plan does not have to reimburse you an additional $250 for hearing aids provided on 
January 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on 
September 25, 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 is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in 
accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-
Paramedic only in certain circumstances.  Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a 
qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer 
ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the 
transport or BLS services.  
 
The Plan has confirmed that  does not have a contract with the volunteer ambulance company that provided the 
transport services. Therefore, we decided that the Plan does not have to pay for paramedic intercept services 
provided to the enrollee on September 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on December 14, 
2021. 
 
You asked the Plan to pay for the services. You say that you have been billing this plan for this patient since 
April 29, 2021. The Plan denied your request. The Plan says Original Medicare would be responsible for 
payment of these services. 
 
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 an office visit provided to the enrollee on December 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital outpatient clinic visits rendered on September 
22, 2021 to September 29, 2021. 
 
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 the services are not separately payable. 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 G0463 
is a column II code to column I code 96365. 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 the hospital outpatient clinic visits rendered on September 22, 
2021 to September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bidet toilet provided on December 17, 2021. 
 
You asked the Plan to pay for a bidet toilet. You say that you have been told by a representative of the Plan that 
the item at issue would be approved as durable medical equipment. The Plan denied your request. The Plan 
says the item at issue is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that bidet toilets are not covered because 
they are not medical equipment. 
 
While a bidet toilet 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 pay for a bidet toilet provided on December 17, 2021.  
 
Your complaint about receiving erroneous or misleading information about your benefits from a representative 
of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from 
December 2, 2021, through December 17, 2021. 
 You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed based on the 
medical documentation. The Plan denied your request. The Plan says the criteria for SNF care were not met. 
 
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 the SNF care. Our reviewer says that the 
provided SNF care was not medically reasonable and necessary. Our physician reviewer found the beneficiary 
was a 79 year old female with hepatocellular carcinoma, chronic obstructive pulmonary disease, diabetes, 
depression, congestive heart failure and chronic pain. In this case, there were no identifiable skilled nursing 
service needs and no identifiable skilled therapy service needs. In conclusion, the beneficiary did 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from December 2, 2021, through December 17, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 30, 
2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) 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 lab 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 laboratory services provided to the enrollee on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vascular surgical services provided on April 1, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vascular surgical services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were provided out-of-network and were 
not approved in advance. 
 
 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 the vascular surgical services provided on April 1, 
2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on October 28, 2021. 
 
You asked the Plan to pay for the anesthesia services. You say that the patient was not on hospice on this date. 
The Plan denied your request. The Plan says Original Medicare is responsible for this claim. 
 
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 27, 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 anesthesia services 
provided on October 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on October 14, 
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 Procedural Coding System (HCPCS) code J7328-RT (1 unit) remains not 
supported, as Gelysn-3 should be billed with 168 units for each injection administered. 
 
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 J7328 is "Hyaluronan or derivative, gelsyn-3, for intra-
articular injection, 0.1 mg." 
 
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 not supported by the medical records. Our reviewer found the number of units billed on claim 
and the Explanation of Benefits (EOB) show 178 units. Per the coding guidelines, Gelsyn-3 has a dosage of 0.1 
MG with Bill units of 168. There was an error in the number of units. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for injection services provided to the enrollee on October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the grab bars provided on December 10, 2021 by an out-of-
network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without prior authorization. 
 
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 the grab bars provided on December 10, 2021 by 
an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing services provided from 
November 16, 2021, to December 10, 2021. 
 
You asked the Plan to waive the copayment for skilled nursing services. You say that you wanted to leave 
earlier so this should be covered. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $0 
copayment per day, days 1 through 20; $178 copayment per day, days 21 through 100 for each SNF stay. You have been asked to pay a total of $2,370, which is less than the standard total copayment for this SNF stay 
because you met your maximum out-of-pocket. Skilled nursing services falls within the Skilled nursing facility 
(SNF) care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for skilled nursing services 
provided from November 16, 2021, to December 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 27, 2021.