Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a car mount for wheelchair (E1399). 
 
You asked the Plan to pre-approve a car mount. You say that you need a holder for your scooter in the back of 
your car. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a car mount for wheelchair (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on December 28, 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 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 (0012M) provided on December 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, Glyb/Metform Tab 5-500mg. 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the drug, Glyb/Metform 
Tab 5-500mg.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that the enrollee does not meet the Medicare guidelines 
for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the complexity of the enrollees nursing, medical, and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee requires treatment by 
multiple therapies, including physical therapy and occupational therapy, at least 3 hours per day, 5 days per 
week. The documentation states that there is a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
an IRF admission and services.  
 
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 genetic testing (81479) provided on February 3, 2023. 
 
You asked the Plan to pay for genetic testing. You say that this test was medically necessary. The Plan denied 
your request. The Plan says the test at issue is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will only reimburse approved tests 
covered for dates of service consistent with the effective date of the coverage determination. 
 
We looked at the file and Medicare rules. This test is not listed by MolDX as an approved test with a DEX 
identifier. Based on this information, we decided that Medicare rules for coverage of genetic testing have not 
been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided on 
February 3, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 11, 2022, billed with 
codes 81163, 81292, 81295, 81298, 81307, 81317, 81408, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. 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 
August 11, 2022, billed with codes 81163, 81292, 81295, 81298, 81307, 81317, 81408, & 81479.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 8, 2022, billed 
with codes 81401, 81405, 81406, 81407, 81408, 81479, 81210, and 81312. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. 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 
November 8, 2022, billed with codes 81401, 81405, 81406, 81407, 81408, 81479, 81210, and 81312.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from November 23, 2022, to 
December 5, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. In this case, the Plan denied payment for the home health services because the 
provider did not send the notice of admission (NOA) to the Plan until May 5, 2023. However, the Plan did not 
provide an NOA with the date of May 5, 2023, for review. We are unable to verify if the denial is correct 
without the NOA this denial was based on. Therefore, we decided that the Plan has to pay for the home health 
services provided from November 23, 2022, to December 5, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 09, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. 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 a home visit provided on 
February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 23, 2023, billed 
with Evaluation and Management (EM) code 99223. 
 
You asked the Plan to pay for the Practitioner service provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid place of 
service. 
 The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face-to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner service provided have not been met. This claim was inappropriately billed with 
POS 21 as the patient was registered as outpatient on this date of service. Therefore, we decided that the Plan 
does not have to pay for Practitioner services provided on January 23, 2023, billed with Evaluation and 
Management (EM) code 99223.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87640 and 87641 for date of service March 
21, 2023. 
 
You asked the Plan to pay for procedure codes 87640 and 87641. 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. Medicare rules say that specific does must be reported as the principal/ 
first-listed diagnosis only. 
 
We looked at the file and Medicare rules. Review of the file shows that diagnosis Z01.818 may only be used as 
first listed or primary diagnosis position. This diagnosis code was not billed as the first listed/primary 
diagnosis. Based on this information, we decided that Medicare rules for coverage of procedure codes 87640 
and 87641 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
87640 and 87641 for date of service March 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on 
December 1, 2022, to December 31, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the SNF services. You say that you are requesting a redetermination of this claim 
as it denied in error for no inpatient authorization. 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 skilled nursing facility (SNF) services 
provided on December 1, 2022, to December 31, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99221 billed for March 7, 2023. 
 
You asked the Plan to pay for procedure code 99221. You say that the service at issue was a medical necessity 
for the enrollee. 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 providers must report services correctly. 
 
In this case, we find that CPT code 99221 is not supported. Specifically, the service at issue was reported with POS code 21, indicating an inpatient location and services. The case record does not support that the enrollee 
was admitted as an inpatient on the date of service. Based on this information, we decided that Medicare rules 
for coverage of procedure code 99221 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 99221 billed for March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that the enrollee unable to do a fingerstick. The Plan 
denied your request. The Plan says the Medicare criteria was not met. 
 
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. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the provided records in this case do not 
document the enrollee is insulin treated or has had problematic hypoglycemia. Records document that the 
enrollee has normal bilateral motor strength, and they are alert and oriented with intact memory and judgement. 
Records do not document trial and failure of teaching by a medical provider or diabetic teaching specialist in 
proper techniques for fingerstick glucose monitoring. Records do not document that a family member or 
caregiver could not assist the enrollee in performing a fingerstick. Although there may be instances where an 
exception to a Medicare LCD may be considered, in this case the records do not support that an exception to 
the LCD Glucose Monitors L33822 criteria is warranted. 
 
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 have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit services provided on January 25, 2023, to 
February 22, 2023, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the OON office visit services. The Plan denied your request. The Plan says the 
OON services were not pre-authorized.  
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, 
we decided that the Plan does not have to pay for office visit services provided on January 25, 2023, to 
February 22, 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 the inpatient hospital services provided from January 17, 
2022, to January 18, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services have 
been met. You are appealing the denial of payment for the inpatient admission provided from January 17, 2022, 
to January 18, 2022. The case file shows that you submitted medical records for three different inpatient 
hospital admissions; however, the medical records did not include inpatient hospital services provided from 
January 17, 2022, to January 18, 2022. Therefore, we decided that the Plan does not have to pay for the 
inpatient hospital services provided from January 17, 2022, to January 18, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 28, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on September 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0117U) provided on January 12, 2023. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary and is supported 
in the medical record. The Plan denied your request. The Plan says you billed with an incorrect place of service 
on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (0117U) provided on January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on December 14, 2022. 
 
You asked the Plan to pay for the acupuncture services. You say that you had to reschedule this appointment 
after getting COVID-19. 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 acupuncture services 
provided on December 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided on February 08, 
2023. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that the services should be covered. 
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 psychiatric diagnostic 
evaluation provided on February 08, 2023.