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

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 1, 2023, to February 13, 2023.

You asked the Plan to pay for SNF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy needs. He did not require daily skilled nursing or daily skilled therapy services. As a practical matter, the enrollee did not require the necessary services on an inpatient basis at the SNF level of care for the dates of service at issue.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from February 1, 2023, to February 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 71271, defined as computed tomography, thorax, low 
dose for lung cancer screening, without contrast material(s) performed on April 10, 2023. 
 
You asked the Plan to pay for 71271. You say that 71271 should be covered because it is supported in the 
record, and it was billed with an accurate diagnosis code. The Plan denied your request. The Plan says 71271 is 
denied because it was billed with an inappropriate diagnosis code.  
The Plan must follow Medicare rules. Medicare rules say that claims for LDCT for lung cancer screening billed 
with diagnoses other than Z87.891, F17.210, F17.211, F17.213, F17.218 and F17.219 with dates of service 
after October 1, 2015, will be denied. 
 
We looked at the file and Medicare rules. The documentation shows a diagnosis code of Z12.2, defined as 
encounter for screening for malignant neoplasm of respiratory organs. This diagnosis is not listed as a covered 
diagnosis for LDCT for lung cancer screening. Based on this information, we decided that Medicare rules for 
coverage of 71271 have not been met. Therefore, we decided that the Plan does not have to pay for code 71271, 
defined as computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) 
performed on April 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leadless pacemaker insertion. 
 
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 are not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers leadless pacemakers when 
procedures are performed in Food and Drug Administration (FDA) approved studies. 
 
We looked at the file and Medicare rules. The file shows that the services are not being requested as part of a 
FDA-approved study. 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 leadless pacemaker 
insertion.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481) provided on April 4, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed 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, the CPT Code Manual definition of code G0481 is Drug Testing, Definitive, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the lab order provided does 
not document the method of testing. 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 lab services 
(G0481) provided on April 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on October 15, 2022. 
 
You asked the Plan to pay for the physician services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the billed code cannot be paid. 
 
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 99223 is initial hospital care. 
 
We find that CPT code 99223 is not supported in the medical record. Specifically, the same provider reported 
multiple instances of initial hospital care on the same claim. Based on this information, we decided that 
Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services (99223) provided on October 15, 2022.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Lutathera.

You asked the Plan to pre-approve Lutathera. You say that progression while on an octreotide product is not part of the FDA-approved indication. The Plan denied your request. The Plan says that the enrollee has not progressed on an octreotide acetate injection product.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Lutathera. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found Lutathera is a radiolabeled somatostatin analog indicated for the treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), including foregut, midgut, and hindgut neuroendocrine tumors in adults. The package insert does not mention failure of Sandostatin.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lutathera have not been met. Therefore, we decided that the Plan has to pre-approve Lutathera.

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 the laboratory services provided on March 13, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on March 13, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for lab services (88185, 88368, 88184, 88369) provided on January 19, 
2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says that another provider was already paid for these services. 
 
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 has denied the billed services stating that another provider was already 
paid for these services. The plan has not provided documentation to the IRE demonstrating that another 
provider was paid for these procedure codes. Therefore, we decided that the Plan has to pay for lab services 
(88185, 88368, 88184, 88369) provided on January 19, 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 nursing facility care provided on February 3, 2023, by an 
out-of-network (OON) provider.  
 
  You asked the Plan to pay for nursing facility care. You say that the enrollee could not go to an in-network 
provider because you are the only company contracted with the nursing home. The Plan denied your request. 
The Plan says that the provider and the nursing home are both out of network and there is no valid referral on 
file. 
 
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 nursing facility care provided on February 3, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 25, 2023, billed with 
evaluation and management (EM) code 99285. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this procedure is included in the global surgery 
period of procedure code 12001. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed and reported with modifier -25. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the practitioner services provided have not been met. Procedure code 99285 was not billed with the 
required modifier. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on April 25, 2023, billed with evaluation and management (EM) code 99285.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 24, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on May 24, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) coded E0675 and 
half leg appliance coded E0673 billed for April 5, 2023. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for E0675 will be denied as not 
reasonable and necessary.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0675. These services are 
denied by Medicare as not medically necessary. Given that the E0675 PCD is not covered, the half leg 
appliance billed with code E0673 is also not covered. Therefore, we decided that the Plan does not have to pay 
for the pneumatic compression device (PCD) coded E0675 and half leg appliance coded E0673 billed for April 
5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you have 
attached all records and paperwork for review and believe medical necessity has been met for the E0652 
Flexitouch device. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for 
an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device 
of either E0650 or E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided.  Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultralightweight wheelchair and accessories coded as 
K0005, E2219, K0040, E0951. 
 
You asked the Plan to pre-approve a wheelchair. You say that the current manual wheelchair is a standard non-
custom ProBasics K4 that does not have the adjustability required for the enrollee to be an active user to self-
propel for functional activities of daily living. The Plan denied your request. The Plan says the current 
wheelchair was delivered less than 5 years ago (2021), and the enrollee's current condition has not changed and 
there has been no mobility evaluation by the primary care provider.  
 
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 a lightweight wheelchair (K0004). The lightweight wheelchair (K0004) serves the 
same purpose as the requested wheelchair. Therefore, we decided that the Plan does not have to pre-approve an 
ultralightweight wheelchair and accessories coded as K0005, E2219, K0040, E0951.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven additional home health skilled nursing visits.  

You asked the Plan to pre-approve home health services. You say that you disagree with the denial. 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 the enrollee 
does not have any documented skilled nursing needs. The feeding tube was recently removed and he is able to 
provide the required daily dressing care. The records do not support that the continued seven home health 
skilled nursing visits are reasonable and medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on May 17, 2023. 
 
You asked the Plan to pay for the anesthesia services. You say that you are in-network with the Plan. The Plan 
denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible which applies to anesthesia services.  
 
The item or service you asked the Plan to pay for falls within the anesthesia services benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies 
to anesthesia services. This cost sharing is a contractual obligation that had not been met at the time the 
anesthesia services was received on May 17, 2023. Therefore, we decided that the Plan does not have to pay for 
anesthesia services provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for physician's services to be 
provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve an in-network exception for physician's services to be provided by the 
requested out-of-network provider. You say that this physician closely watches your glaucoma and knows 
when to respond and specializes in treatment and surgeries for glaucoma. You say that there are no other 
providers who are able to treat your severe glaucoma. The Plan denied your request. The Plan says the Plan has 
two providers who are in-network that are able to treat the enrollees glaucoma within a similar distance from 
the enrollees home. 
 
The Plan contract says that you can choose to receive care from out-of-network providers. However, if you use 
an out-of-network provider, your share of the costs for your covered services may be higher.    
 
We looked at the file and the Plans rules. The file shows that you can choose to receive care from out-of-
network providers. However, if you use an out-of-network provider, your share of the costs for your covered 
services may be higher. The file shows that the Plan has in-network providers who are able to treat your 
glaucoma and are within a similar distance from your home as the out-of-network provider. Therefore, we 
decided that the Plan does not have to pre-approve an in-network exception for physician's services to be 
provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 07, 2022, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for these chiropractic services. You say that the provider told you the services would 
not be covered. The Plan denied your request. The Plan says that the provider is not under contract with the 
health plan and is not certified for Medicare. Medicare rules say that in order to receive payment for covered items or services, a provider must be enrolled 
in the Medicare program. The contract with the Plan says that the Plan cannot pay for services from a non-
Medicare provider, except for emergency care. 
 
This provider is not enrolled in the Medicare program and is not payable. 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 
chiropractic services provided on July 07, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455 with a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 81456 billed for date of service March 29, 2023.