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

 
We decided that the Plan does not have to pre-approve the Invitae BRCA1, BRCA2 (breast cancer 1 and 2) 
panel (81162). 
 
You asked the Plan to pre-approve the laboratory service. You say that the medical records provided support 
the necessity of the services in dispute.  The Plan denied your request. The Plan says under Medicare, the 
genetic testing, Invitae BRCA1/2 Panel, requested does not meet the requirements for approval.  
 
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 laboratory service. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Invitae BRCA1, BRCA2 panel (81162) is not medically reasonable and necessary 
in this case. The records do not show that the enrollee has either recurrent, relapsed, refractory, metastatic, or 
advanced stage III or IV cancer and has decided to seek further cancer treatment (e.g., therapeutic 
chemotherapy). 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Invitae BRCA1, BRCA2 (breast cancer 1 and 2) panel (81162).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 15, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. The Plan denied your request. The Plan 
says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee's condition requires this. The Plan 
denied your request. The Plan says a ventilator is not covered by Medicare for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee was unable to tolerate a bilevel positive 
airway pressure device. The Plan denied your request. The Plan says a ventilator is not covered by Medicare 
for this purpose because it is only going to be used in a bilevel pressure mode as a respiratory assist device. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide positive 
airway pressure (PAP) therapy, regardless of the underlying medical condition, shall not be covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve use 
of a ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you need oxygen all the time and need to go to 
the provider. The Plan denied your request. The Plan says the services are not covered for use outside of the 
home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care billed for dates of service April 14, 
2022, to April 29, 2022. You asked the Plan to pay for the billed services. You say that the NOA was billed after the end date of service. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is March 15, 2022. The NOA was not received by the Plan until June 9, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health care billed for dates of 
service April 14, 2022, to April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block (64454). 
 
You asked the Plan to pre-approve the nerve block. You say that the enrollee does not want surgery. You also 
say that the enrollee would like to proceed with a genicular nerve block. The Plan denied your request. The 
Plan says the efficacy of this procedure has not been established and therefore it cannot be covered. 
 
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 nerve block. Our reviewer says that 
the requested nerve block is not considered medically reasonable and necessary in this case. Our physician 
reviewer found this procedure is the subject of ongoing clinical trials and is considered experimental.  
Therefore, the reviewer found that the requested nerve block is not medically reasonable and 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 nerve block have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a genicular nerve block (64454).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing was medically necessary. The Plan 
denied your request. The Plan says an incorrect place of service was billed. 
 
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 claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on December 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services billed for dates of service 
September 22, 2022, to January 19, 2023. You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the NOA was 
not received timely. As such, this final claim was correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is September 22, 2022. The NOA was not received by the Plan until February 
7, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for the home health care services 
billed for dates of service September 22, 2022, to January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmental pneumatic appliance for use with 
pneumatic compressor (E0667) and pneumatic compressor (E0651) to be rendered by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a segmental pneumatic appliance and pneumatic compressor. You say that 
the enrollee needs to be taught how to use this equipment with a medical nurse only. You also say that the 
doctor only wants a nurse from the durable medical equipment (DME) company that they provide. The Plan 
denied your request. The Plan says the request to use an OON provider for the services does not meet the 
requirements for approval. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 a segmental pneumatic appliance and 
pneumatic compressor. Our reviewer says that the provided medical records indicate a referral was 
recommended for evaluation for a lymphedema pump but medical records in this case do not support that the 
specific Medi Genius pump is medically necessary due to the severity of the enrollee's condition. Our physician 
reviewer found a review of the health plan's medical equipment suppliers indicates local availability of an in-
network supplier of lymphedema pumps which would appear to provide adequate care for the enrollee. Our 
reviewer also found that the medical records do not document anything unique about the enrollee's condition 
that that would make it medically necessary for them to get these items through the requested OON provider. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a segmental pneumatic appliance and pneumatic compressor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a segmental pneumatic appliance for use with 
pneumatic compressor (E0667) and pneumatic compressor (E0651) to be rendered by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you for the fitness equipment provided on August 22, 2022 and 
November 12, 2022. 
 
You asked the Plan to reimburse you for the fitness equipment. You say that you use the fitness equipment to 
reduce of relieve your back and neck pain and not for recreational use. The Plan denied your request. The Plan 
says that the fitness equipment is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided documentation that shows that the fitness 
equipment was purchased for recreational use and does not meet the coverage criteria under the Wellness 
Wallet benefit for home fitness equipment. The Plan has not substantiated their denial. Therefore, we decided 
that the Plan has to reimburse you for the fitness equipment provided on August 22, 2022 and  
November 12, 2022.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient admission after dental surgery. 
 
You asked the Plan to pre-approve inpatient admission after dental surgery. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers inpatient 
admission after dental surgery when the services are medically necessary and reasonable.  
 
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 inpatient admission after dental surgery. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
does not sufficiently demonstrate that inpatient admission after dental surgery will be medically necessary for the enrollee in this case. It has not been shown that it is reasonable for the admitting provider to expect that the 
enrollee's necessary post-surgery will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of inpatient admission after dental surgery have not been met. Therefore, we 
decided that the Plan does not have to pre-approve inpatient admission after dental surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need transportation to attend 
your radiation treatments. The Plan denied your request. The Plan says you have used eighteen (18) one-way 
trips of the eighteen (18), one-way trips covered by your health plan for the year 2023. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 18 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Hillrom Life2000 device (E0466). 
 
You asked the Plan to pre-approve the Hillrom Life2000 device. You say that the enrollee is extremely short of 
breath with any activity and needs the support the Lfe2000 portable ventilator. The Plan denied your request. 
The Plan says the Life2000 does not meet the Medicare requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. The Life2000 system is not a true ventilator because it is not capable 
of providing full ventilatory support. It is designed primarily for use during activity. The current medical 
literature does not consider this device to be standard medical treatment for the enrollee's condition.  Based on 
this information, we decided that Medicare rules for coverage of the Hillrom Life2000 device have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the Hillrom Life2000 device (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on August 5, 2022. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0013M) provided on August 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 25, 2022, billed with 
codes 87502, 87581, 87634, 87651, 87798, U0003 and U0005. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says panel testing should be billed using one CPT 
code on the claim. 
 
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 
October 25, 2022, billed with codes 87502, 87581, 87634, 87651, 87798, U0003 and U0005.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency room visit provided on March 28, 2023. 
 
You asked the Plan to pay for emergency room visit. You say that you are appealing this denial. The Plan 
denied your request. The Plan says that this provider is not certified to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan denied payment for this service on the basis that the provider is a non-
Medicare approved freestanding emergency facility. However, freestanding emergency facilities were allowed 
to participate in Medicare on an interim basis during the COVID-19 Public Health Emergency (PHE) period 
which includes the date of service in question. The Plan did not show that the provider was ineligible to 
participate as a freestanding emergency facility, nor did the Plan provide any other evidence or rationale to 
support a denial of payment for this service. Therefore, we decided that the Plan has to pay for an emergency 
room visit provided on March 28, 2023.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 11, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the OON office visit. You say that the medical records provided support the need 
for the services in dispute.  The Plan denied your request. The Plan says there was no valid authorization for 
the OON services provided.  
 
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 provided on April 11, 2023, by an 
out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that it is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found there is no 
evidence the enrollee is home bound. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.