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

 
We decided that the Plan does not have to pay for the CxBladder test provided on August 12, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test determines the probability of urothelial 
carcinoma being present. The Plan denied your request. The Plan says the test is not covered. 
 
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 CxBladder test provided on August 
12, 2021. have not been met. Specifically, there are no medical records to demonstrate that the use of the 
biomarkers will be used to assist in the management of the enrollee. Therefore, we decided that the Plan does 
not have to pay for the CxBladder test provided on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you need this because 
your blood pressure is getting higher. The Plan denied your request. The Plan says you were provided a wrist 
blood pressure monitor on August 31, 2021. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have wrist blood pressure monitor. A wrist blood pressure monitor serves the same 
purpose as an automatic blood pressure monitor. Therefore, we decided that the Plan does not have to pre-
approve an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99204) and the urine capacity measurement 
(51798) rendered by the out-of-network (OON) provider on August 11, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99204) and the urine capacity measurement (51798) rendered by 
the out-of-network (OON) provider on August 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the upper endoscopy with biopsy (43239) 
provided on September 22, 2021. 
 
You asked the Plan to waive the copayment for the endoscopy procedure. You say that these services were 
necessary and therefore a cost-share should not apply. The Plan denied your request. The Plan says this claim 
was processed correctly, and your cost-share was assessed in accordance with your contract. This service is 
covered, and you are responsible for a $350 copayment for in-network outpatient surgery services. 
 
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 $350 
copayment for outpatient surgery services.  
 
 You have been asked to pay a $350 copayment for the endoscopy procedure. The endoscopy procedure falls 
within the outpatient surgery 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 
the upper endoscopy with biopsy (43239) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99213) provided on May 20, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a specialist office visit. You say that prior authorization is not required for an 
office visit. The Plan denied your request. The Plan says the unauthorized services rendered were by a non-
participating provider. The Plan also says that it was determined that the services received were not 
urgent/emergent, and the member does not have out of network coverage for services determined to be non-
urgent/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 specialist office visit (99213) provided on May 
20, 2021, by an out-of-network (OON) provider.
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. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 there are no acute rehabilitation or nursing needs noted in the record. The 
enrollee is medically stable and does not need physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy. IRF admission is not medically necessary based on lack of medical 
complexity, and lack of acute rehabilitation and nursing needs. Needs can be safely met in an alternate and 
lower intensity setting, such as a skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (88341) provided on April 29, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that no units were paid for this date of service. The 
Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a 
non-network provider with the member's Plan, and another non-network provider with the member's Plan 
referred the member for services. The Plan also says they require utilization of network providers when 
possible and available and required authorization for certain services. The Plan also says there is no necessity 
for an out-of-network provider, such as urgent or emergency situation has been documented.  
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 laboratory services (88341) provided on April 29, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Consumer Directed Personal Assistance Services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. This request is not a covered type of home health services for 
Medicare beneficiaries. 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 pre-approve Consumer Directed 
Personal Assistance Services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing for services billed on June 28, 2021. You asked the Plan to pay for the services provided. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the validity and accuracy of the claim cannot be 
verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
The file shows that Guardant360 testing was provided. We looked at the file and the rules. We find that the 
claim lists a place of service as an independent laboratory. The records do not show that the specimen was 
obtained at an independent laboratory. The records also show that the date the specimen was collected is not 
the date of service at issue in this appeal. 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 lab testing for services billed on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99202) provided on March 16, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for office visits. 
The Plan denied your request. The Plan says the unauthorized services rendered were by a non-participating 
provider. The Plan also says that it was determined that the services received were not urgent/emergent, and the 
member does not have out of network coverage for services determined to be non-urgent/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 an office visit (99202) provided on March 16, 
2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report 
rendered on August 18, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 93000 (EKG interpretation and report) and 93288 
(interrogation device evaluation). Code 93000 is a column II code with a modifier indicator of 1 when billed 
with column I code 93288. Code 93000 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) 
interpretation and report rendered on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 11, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the genetic testing provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the rollator/walker and adjustable shower extension arm and 
compression stockings purchased July 1, 2020 to March 25, 2021. 
 
You asked the Plan to pay for the medical supplies. You say that you are enclosing receipts and other 
supporting documents, although the medical necessity of these items should be well documented in the records. 
The Plan denied your request. The Plan says the both suppliers are not Medicare certified providers and the 
items purchased June 1, 2020 and June 26, 2020 was submitted after the timely filing limitation. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the rollator/walker and adjustable 
shower extension arm and compression stockings purchased July 1, 2020 to March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with 
insulin three times a day or use an insulin pump. 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 Dexcom G6 continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature is non-covered. 
 
We looked at the file and Medicare rules. The item at issue is a power seat elevation feature. This item is non-
covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve the power seat 
elevation system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (procedure code 
14301) provided to the enrollee on March 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 the code cannot be verified. 
 
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 14301 is "Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm." 
 
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 that in this case, the record indicates 
that the enrollee underwent a procedure. The procedure note documents that excess skin was removed. The 
record does not indicate that tissue transfer or rearrangement was performed. The record indicates that 
advancement was performed. The elements of the coverage criteria are not satisfied.  
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 adjacent tissue transfer or rearrangement (procedure code 14301) provided to the enrollee on 
March 25, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (76705) provided on October 5, 2021. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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 76705 
is a column II code to column I code 93976. 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 services (76705) provided on October 5, 2021.
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. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 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 enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from August 20, 2021, 
to September 18, 2021. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility 
(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 skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from August 20, 2021, to September 18, 
2021.