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

 
We decided that the Plan does not have to pay for the drug testing provided on April 22, 2021. 
 
You asked the Plan to pay for the drug testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this was billed with an incorrect POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that for 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. The documentation does not indicate this sample was taken by the 
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that 
Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing provided on April 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
(A0998) provided on September 11, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you would 
like reconsideration because you needed emergency services and believe there should be a benefit for the 
services provided. The Plan denied your request. The Plan says you received treatment on-site at your home 
and declined transportation to the hospital. 
 
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 September 11, 2021. 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 the ambulance response and treatment without 
transport (A0998) provided on September 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81223). 
 
You asked the Plan to pre-approve the genetic testing. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the genetic testing. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found cystic fibrosis transmembrane conductance regulator (CFTR) genetic testing was requested. 
However, this test is only approved for a person of reproductive age. There was no support made that this 
testing would lead to a change in care or overall outcome. 
 
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 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81223).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not 
medically necessary. 
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours 
over 7 consecutive days, of therapy services. Therapy services may be provided at a lower 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on October 26, 2021. 
 You asked the Plan to pay for a CT scan of the head or brain. You say that the procedure at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met 
because the CPT code at issue is inclusive to another billed code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain (70450) 
provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided April 27, 
2020 to April 30, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you should receive 100% of the Medicare 
allowable. When this claim was reprocessed, it was underpaid and recouped payment that is due to you. The 
Plan denied your request. The Plan says it is not possible to verify the level of care provided to the enrollee 
during this SNF stay. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the skilled nursing facility (SNF) 
services provided April 27, 2020 to April 30, 2020 have been met. the Plan had made multiple attempts to 
obtain medical records from the provider without success. Therefore, we decided that the Plan does not have to 
pay for the skilled nursing facility (SNF) services provided April 27, 2020 to April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip arthroscopy surgery. 
 
You asked the Plan to pre-approve hip surgery. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is 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 hip surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evidence regarding trial and failure of recent, reasonable, and 
comprehensive less invasive conservative measures. There is no compelling rationale or extenuating 
circumstance noted to support the necessity of this procedure as an exception to guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hip surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hip arthroscopy surgery.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound (76700) provided on October 
14, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the services should be covered at a 
higher rate as they were performed in an office setting. The Plan denied your request. The Plan says the cost-
sharing applies correctly based on the services provided. 
 
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 $150 
copayment for Advanced Imaging Services at an Independent Diagnostic Testing Facility (IDTF).  
 
 
 
 
 
 You have been asked to pay a $150 copayment for an ultrasound. The record indicates that the services were 
received in an outpatient setting. Ultrasounds fall within the Outpatient diagnostic tests and therapeutic services 
and supplies 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 an ultrasound (76700) 
provided on October 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for psychotherapy services (90832) provided on June 24, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for 
the enrollee's care. The Plan denied your request. The Plan says that rules for payment have not been met 
because the provider has not documented an attempt to consult the enrollee's attending or primary care 
physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the Clinical Psychologist must attempt to consult 
the enrollee's attending or primary care physician about the provided services. This does not apply if a 
physician referred the enrollee to the Clinical Psychologist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have been met. Specifically, the case record clearly indicates that the 
enrollee was referred for these services by a physician. The rules regarding consultation with the enrollees 
attending or primary care physician do not apply if a physician has referred the enrollee to the clinical 
psychologist. Therefore, we decided that the Plan has to pay for psychotherapy services (90832) provided on 
June 24, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 14, 2021, and 
August 15, 2021. 
 
You asked the Plan to pay for the physician's services. You say that the patient was seen for non-hospice 
related services and the provider is not affiliated with the hospice carrier. 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 physician's services provided on August 14, 2021, and 
August 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self administered drugs provided on October 8, 2021, 
through October 11, 2021. 
 
You asked the Plan to pay for the self administered drugs. You say that you would like reconsideration because 
you needed an IV and were not able to administer the drugs yourself. The Plan denied your request. The Plan 
says self administered drugs are not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self administered drugs 
provided on October 8, 2021, through October 11, 2021.   
Benefits for the self administered drugs 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on October 4, 2021, 
and October 5, 2021. 
 You asked the Plan to pay for therapeutic exercises. You say that this claim was billed appropriately and should 
be paid. The Plan denied your request. The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find 
that CPT code 97110 is not supported in the medical record as billed. Specifically, the documentation shows 
that this claim was billed by a Nurse Practitioner but the therapy services at issue were rendered by a Physical 
Therapy Assistant. There is no indication that the Nurse Practitioner was present on site while the therapy 
services were being rendered. The incident-to requirements have not been met in this case. Based on this 
information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. 
Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on October 
4, 2021, and October 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 14, 2021, to December 16, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered as you had a small room. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $335 
copayment per day for days 1-6 of Inpatient hospital care.  
 
 You have been asked to pay a $670 copayment for two days of inpatient hospital care. 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 an inpatient hospital stay provided from December 14, 2021, to 
December 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cosentyx. 
 
You asked the Plan to pre-approve Cosentyx. You say that Cosentyx is medically necessary. The Plan denied 
your request. The Plan says Cosentyx is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cosentyx.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the microprocessor ankle (L5973). 
 
You asked the Plan to pre-approve the microprocessor ankle. You say that you would like reconsideration 
because the requested equipment is medically necessary. The Plan denied your request. The Plan says the 
requested microprocessor ankle is 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 the microprocessor ankle. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the records report that the enrollee wants a lighter weight foot that will allow him to 
be active outdoors where he enjoys hunting and fishing. Records do not explain why a K3 mechanical foot 
(which is lighter weight and less prone to water damage than the requested microprocessor foot) would not be 
appropriate for the enrollee. Records do support that the enrollee has a functional level of 3. 
 
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 microprocessor ankle have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the microprocessor ankle (L5973).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested provider is not a Medicare-participating 
provider eligible to bill for services and does not participate in the Plans network of providers. 
  
 
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. Additionally, the 
rules state that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary 
unless the provider or supplier is enrolled in the Medicare program. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Additionally, Medicare rules state that no provider or supplier shall receive 
payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the 
Medicare program. The requested provider in this case is not enrolled in the Medicare program. Therefore, we 
decided that the Plan does not have to pre-approve acupuncture treatment to be rendered by the out-of-network 
(OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pantoprazole 40mg tablets. 
 
You asked the Plan to pre-approve Pantoprazole. You say that Pantoprazole is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Pantoprazole 40mg tablets.  
 
Benefits for Pantoprazole 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for a laparoscopy with bilateral total pelvic lymphadenectomy (38571) 
billed for date of service October 11, 2021. 
 
You asked the Plan to pay for a laparoscopy with bilateral total pelvic lymphadenectomy. You say that the 
service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says that the 
provided records do not support the service billed. 
 
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 38571 is "Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy." 
 
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 a laparoscopy with bilateral total pelvic lymphadenectomy. 
Our reviewer says that the billed service at issue meets criteria for reimbursement. Our reviewer found that the 
provided medical records support that the billed procedure code 38571 with modifier 22 was provided on 
October 11, 2021. The operative record indicates that extended bilateral total pelvic lymphadenectomy was 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a laparoscopy with bilateral total pelvic lymphadenectomy have been met. 
Therefore, we decided that the Plan has to pay for a laparoscopy with bilateral total pelvic lymphadenectomy 
(38571) billed for date of service October 11, 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.