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

 
We decided that the Plan does not have to pay for procedure codes 99072, 94761, and 87631 billed for date of 
service June 8, 2022. 
 
You asked the Plan to pay for the billed services. You say that medical records were provided.  The Plan 
denied your request. The Plan says the codes are not payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. Procedure code 
94761, billed on the same date as payable code 94664, has a status indicator of T. This means that procedure 
codes 99072 and 94761 are not separately payable.  
 
We find that the claim does not show that the required unique identifier was reported for procedure code 
87631. Based on this information, we decided that Medicare rules for coverage of the billed services have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99072, 94761, and 
87631 billed for date of service June 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation (A0120). 
 
You asked the Plan to pre-approve additional routine transportation. You say that you exhausted the 72 rides 
for transportation and need additional rides to go substance abuse. You also say that you go to this Monday 
through Friday, and can get very sick if you do not go continuously everyday how you should be going. The 
Plan denied your request. The Plan says this request exceeds the benefit limit set in the agreement for routine 
transportation.  
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 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows as of May 26, 2023, you 
had two trips remaining, and you will have exceeded the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation (A0120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant Reveal testing provided on October 5, 2022.  
 
You asked the Plan to pay for the Guardant Reveal testing. You say that this is not experimental testing.  The 
Plan denied your request. The Plan says this is not covered by Medicare.  
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. The Guardant Reveal testing is listed as not covered by Medicare in 
the DEX Diagnostic Exchange. Based on this information, we decided that Medicare rules for coverage of the 
Guardant Reveal testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant Reveal testing provided on October 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing (G0480) provided September 29, 
2021. 
 
You asked the Plan to pay for the laboratory service. You say that your claim has been denied for untimely 
filing in error. Please review the attached proof of timely filing and reprocess your claims for payment. The 
Plan denied your request. The Plan says the claim was submitted past the timely filing limitation. 
 
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 laboratory service was not filed until November 8, 2022. 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 the definitive drug testing (G0480) provided September 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99051 billed for date of service October 26, 
2022. 
 
You asked the Plan to pay for procedure code 99051. The Plan denied your request. The Plan says procedure 
code 99051 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99051 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99051 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99051 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99051 billed for date of service October 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says your 100-day limit was met on May 22, 2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from July 29, 2022, through 
May 22, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.  Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuropsychological testing.  
 You asked the Plan to pre-approve neuropsychological testing. You say that neuropsychological testing is 
medically necessary. The Plan denied your request. The Plan says the requested neuropsychological testing is 
not medically necessary.  
 
The Plan follows Medicare rules.  
 
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 neuropsychological testing. Our 
reviewer says that the requested neuropsychological testing is not considered medically necessary in this case. 
Our physician reviewer found that the enrollees documentation shows the enrollee to have cognitive 
complaints. Utilizing the criteria from the Medicare LCD L33632 that this testing is intended to diagnose and 
characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain 
including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, 
differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of 
central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous 
system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, this enrollee does not meet the 
criteria as the enrollee has not had a psychiatric evaluation or memory screening tests that would warrant this 
type of diagnostic treatment and is therefore is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neuropsychological testing have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neuropsychological testing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on January 12, 
2023. 
 
You asked the Plan to pay for the molecular pathology services. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the molecular 
pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
molecular pathology services provided on January 12, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve the Prolia injections. 
 
You asked the Plan to pre-approve the Prolia injections. You say that  due to the enrollee's medical issues 
injection of medication is the best option. The Plan denied your request. The Plan says that the enrollee did not 
meet the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia injection. Our physician reviewer 
found that the Plan requires a trial of drug zoledronic acid before they will approve Prolia. Our physician 
reviewer found that based on the medical records provided there is no indication that the enrollee has tried and 
failed the required drugs. Our physician reviewer found the documentation supports that the use of intravenous 
(IV) zoledronic acid would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia injection have been met. Therefore, we decided that the Plan has to pre-
approve the Prolia injections.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services rendered on July 8, 2022. 
 
You asked the Plan to pay for the services. You say that the claim for the assistant surgeon was paid. Please 
pay the surgeon. The Plan denied your request. The Plan says Medicare says non-urgent services should be 
from network providers who are contracted with the healthplan and listed in the Provider Directory. 
 
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 surgical services rendered on July 8, 2022.
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 June 3, 2022, to June 10, 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 June 3, 
2022, to June 10, 2022.
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 you are requesting an expedited 
reconsideration for the denial of an LTACH admission. The Plan denied your request. The Plan says criteria 
for admission to the LTACH have not been met.  
 
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 the documentation does not support that the enrollee requires services at the 
LTACH that are not available at the acute care hospital where they are currently receiving care There are no 
required medical services identified that are available at the LTACH that are not available at the current health 
care setting being offered by the Plan.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy visits. You say that physical therapy has greatly improved 
the enrollee's physical and emotional state. You say that the enrollee came to their first appointment in a 
wheelchair and is now out and walking. The Plan denied your request. The Plan says additional physical 
therapy visits are not medically necessary.  
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 physical therapy visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the enrollee has previously been treated with outpatient 
therapies and should be independent with a home exercise program. The enrollee has no recent injury or a 
decline in function. The additional therapy services are not appropriate duration and frequency for treatment of 
the enrollees medical condition and therefore are not 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 physical therapy visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for MI Tumor Seek (81479) provided on November 27, 2022. 
 
You asked the Plan to pay for MI Tumor Seek . You say that this testing was medically necessary. The Plan 
denied your request. The Plan says criteria are not met for the requested test. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels may be covered when the enrollee 
has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of MI Tumor Seek have not been met. Specifically, the documentation does not support that the 
enrollee has recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. Therefore, we 
decided that the Plan does not have to pay for MI Tumor Seek (81479) provided on November 27, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivicaine used during an injection procedure on 
February 3, 2023.  
 
You asked the Plan to pay for the bupivicaine. You say that all billed codes should be paid.  The Plan denied 
your request. The Plan says payment for the local anesthetic is included with the injection procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that separate payment for local anesthetic cannot be 
made as this is included in payment for an injection.  Therefore, we decided that the Plan does not have to pay 
for the bupivicaine used during an injection procedure on February 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve continued SNF care. The Plan denied your request. The Plan says a 
continued stay at the skilled level of care is not medically appropriate. 
 
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 pre-approve continued 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 daily skilled nursing needs that require 
the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily 
skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. Our reviewer also found that the enrollee does 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that use insulin three times a day, two 
different kinds and you really need the monitor. You also say that it is already at a pharmacy as the provider 
already ordered it and the insurance is having issues. The Plan denied your request. The Plan says you do not 
meet criteria for the requested CGM and supplies. 
 
 
 The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM and supplies. Our reviewer 
says that the elements of the coverage criteria are not satisfied. Our physician reviewer found the record 
indicates that you have diabetes. The medical records provided are insufficient to establish that all of the 
elements of the coverage criteria are satisfied. 
 
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 CGM and supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a 
total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The 
Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 
2 midnight stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case.  Our physician reviewer found the enrollee is scheduled/approved for a total shoulder arthroplasty. The 
record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 
or more midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.