Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from September 23, 2022, to 
October 17, 2022. 
 You asked the Plan to pay for the home health services. You say that these services were billed correctly and 
you have submitted the required NOA. 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 23, 2022. The NOA was not received by the Plan until 
December 15, 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 home health 
services provided from September 23, 2022, to October 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stress test with a cardiologist. 
 
You asked the Plan to pre-approve a stress test. You say that  this was ordered by the nurse practitioner from 
your primary care physician's office. You also say that you are in need of this to make sure you do not have any 
blood clots that could be endangering to your life. The Plan denied your request. The Plan says your primary 
care physician's office stated that you have not been seen by the cardiologist previously, would first need have 
an initial office visit and based on the cardiologist's recommendations your primary care physician can send the 
referral request for the stress test. 
 
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 a stress test. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a stress test for in a patient with low likelihood of severe coronary artery disease is not 
reasonable and necessary and will not identify the cause of the leg swelling.  Measuring the brain natriuretic 
peptide or an echocardiogram in addition to a thorough physical examination is more appropriate than the 
requested stress test. 
 
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 stress test have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a stress test with a cardiologist.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye examination (92014) provided on January 25, 2023. 
 
You asked the Plan to pay for the eye examination. You say that the Plan should cover this service. The Plan 
denied your request. The Plan says that you have exceeded the benefit limit for this service. 
 
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 did not obtain medical records and we are unable to confirm whether 
this was a routine eye examination. The documentation available in the case file itself is not sufficient to 
determine that it was a routine eye examination. Therefore, we decided that the Plan has to pay for the eye 
examination (92014) provided on January 25, 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 lab services provided on April 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that you were not provided correct insurance 
information by the ordering provider. The Plan denied your request. The Plan says you did not timely file this 
claim. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 
2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for 
the lab services was not filed until January 24, 2023. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for lab services provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services (92012) provided on January 
28, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the vision exam. You say that a provider performing services in a nursing home 
facility is not responsible to obtain authorization. The visit should fall under the authorization of the nursing 
home. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-
network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered. 
 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 ophthalmological services (92012) provided 
on January 28, 2023, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator.  
 
You asked the Plan to pre-approve a home ventilator. You say that a home ventilator is needed to keep the 
patient breathing. The Plan denied your request. The Plan says a home ventilator is not medically necessary 
because the patient's needs can be met with a bilevel positive airway pressure (BiPAP) device with average 
volume-assured pressure support (AVAPS). 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found the enrollee is an 80-year-old 
male with chronic obstructive pulmonary disease (COPD). The submitted pulmonary evaluation includes 
pulmonary function testing (PFT) showing a severe obstructive ventilatory deficit with dynamic hyperinflation 
and a reduced diffusion capacity. Complete arterial blood gas analysis (ABG) results are not available but the 
provider notes aPCO2 = 40.9. A six-minute walk test (6MWT) shows hypoxemia at rest and with exercise. 
There is no evidence to support recent hospital admission. A request is now made for a home mechanical 
ventilator with PS with Safety Tidal Volume mode to assure adequate tidal volume ventilation. The addition of 
volume assurance may benefit this member and the need for positive pressure ventilation is not disputed. 
However, you did not submit a compelling rationale that supports use of a home mechanical ventilator (HMV) 
to deliver this assistance rather than a BiPAP with a backup rate and AVAPS. The member does not appear to 
have the severity of illness that would justify the need for a home mechanical ventilator. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 8, 2022. 
 
You asked the Plan to pay for DecisionDx-SCC testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test has not met Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. Once this is complete, the test is assigned a 
reimbursement rate and a unique test identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of DecisionDx-SCC testing have not been met. Therefore, we decided that the 
Plan does not have to pay for DecisionDx-SCC testing (0315U) provided on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the screening pap smear (G0145) provided on December 20, 
2022. 
 
You asked the Plan to pay for the screening pap smear. The Plan denied your request. The Plan says the 
enrollee has exceeded the frequency limit for this service.  
The Plan must follow Medicare rules. Medicare rules say that a screening pap smear is covered if the enrollee 
has not had a pap smear in the past two years or there is evidence that the enrollee is at a high risk of 
developing cervical cancer. 
 
We looked at the file and Medicare rules. The provided records show that a screening pap smear was 
previously provided on December 16, 2021. The documentation does not show that the enrollee is t a high risk 
of developing cervical cancer. Based on this information, we decided that Medicare rules for coverage of the 
screening pap smear have not been met. Therefore, we decided that the Plan does not have to pay for the 
screening pap smear (G0145) provided on December 20, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for skilled nursing care (99309, 99308) provided from February 3, 2023, to 
February 17, 2023.  
 
You asked the Plan to pay for skilled nursing care. You say that these services were necessary and are 
supported in the medical records. The Plan denied your request. The Plan says that these services were billed in 
a frequency which exceeds the allowed amount. 
 
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 did not provide any of the original claims submitted for 
these services. Without these documents, we cannot verify that these services were billed with either the 
modifier(s) or place of service code which would cause the rule used by the Plan to apply to these services. The 
Plan has not included enough evidence to support their denial in this case. Therefore, we decided that the Plan 
has to pay for skilled nursing care (99309, 99308) provided from February 3, 2023, to February 17, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
June 20, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service June 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncological genetic testing (0012M) billed for date of service 
January 17, 2023. 
 
You asked the Plan to pay for oncological genetic testing. You say that you have billed the service at issue 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage is reaffirmed for CPT codes 
0012M and 0013M for CxBladder. Based on this information, we decided that Medicare rules for coverage of 
oncological genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
oncological genetic testing (0012M) billed for date of service January 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Temporary Implantable Nitinol Device (iTind) System 
(55899, 52282).  
 
You asked the Plan to pre-approve an iTind System. You say that the enrollee is very uncomfortable and needs 
this device.  The Plan denied your request. The Plan says the clinical value and effectiveness of iTind System 
in the setting of benign prostatic hyperplasia (BPH) with obstruction and lower urinary tract symptoms 
(LUTS), have not been demonstrated in the peer-reviewed literature.  
 
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 an iTind System. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the use of an iTind is considered investigational as a treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Further studies are needed to evaluate the durability of iTIND 
outcomes over a longer follow-up, to better define the indications of this approach, and to demonstrate the 
advantages of second-generation device over the first device. ITind is not recommended in the most recent 
American Urological Association (AUA) Guidelines regarding treatment of BPH.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an iTind System have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Temporary Implantable Nitinol Device (iTind) System (55899, 52282).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99203) to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says treatment of CEAP C0 and C1 are considered cosmetic and therefore not reasonable and 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that it is not possible to attribute the enrollee's pain to varicose veins, as the enrollee has multiple risk 
factors for peripheral artery disease, with disabling leg pain without compression. There has been no 
assessment of arterial perfusion. Additionally, the enrollee has a history of prior back surgery and the enrollees 
left great saphenous vein is very small at less than 3 mm throughout its length with no saphenofemoral reflux 
or reflux in the proximal vein. Additionally, the criteria requires provision of the CEAP and VCSS 
scores. These also have not been provided.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation therapy of incompetent vein.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, 
and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively 
only on an inpatient basis. 
 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on December 8, 2022, and 
December 9, 2022, billed with codes 77336, 77525, and G6002. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim 
and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on January 9, 2023, and January 10, 2023. Comparison of the two claims shows these are exact duplicates. There is no evidence presented to support that the billed items/services were provided 
twice on the same date. Based on this information, we decided that the Medicare rules for the radiology 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for radiological 
services provided on December 8, 2022, and December 9, 2022, billed with codes 77336, 77525, and G6002.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on December 8, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test (0315U). You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test (0315U) have not been 
met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided 
on December 8, 2022.