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

 
We decided that the Plan does not have to reimburse to you for  the stationary liquid oxygen system, rental 
(E0439) provided May 20, 2022, to October 1, 2022. 
 
You asked the Plan to reimburse to you for  the oxygen supplies. You say that you are requesting 
reimbursement for oxygen and oxygen supp that was paid for during 2022. 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 (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay 20% coinsurance for Durable medical equipment (DME) and relate supplies.  
 
The Plan has approved payment at the in-network level and the enrollee has to pay 20% coinsurance for the 
oxygen supplies. This item/service falls within the Durable medical equipment (DME) and relate supplies. benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract 
with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
The records also show that the Plan confirmed that the DME supplier will be issuing a refund for the dates that 
were paid out of pocket during May 20, 2022, to June 2, 2022. Therefore, we decided that the Plan does not 
have to reimburse to you for  the stationary liquid oxygen system, rental (E0439) provided May 20, 2022, to 
October 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 6, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you have submitted all 
information needed to process this claim. The Plan denied your request. The Plan says the claim has not been 
billed with the correct admission date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from August 12, 2022, to 
September 6, 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 September 8, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates that these tests are included in the dialysis rate. 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 
September 8, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional miles for routine transportation beyond the 
Plan's 50-mile limit. 
 
You asked the Plan to pre-approve additional mileage. You say that you need additional mileage for 
transportation to treatments. The Plan denied your request. The Plan says the requested trip exceeds your 
mileage limit. 
 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 routine transportation when each one-way trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. In this case the requested trip is greater 
than 50 miles of driving distance. Based on this information, we decided that the Plans rules for coverage of 
routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional miles for routine transportation beyond the Plan's 50-mile limit.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 22, 2022, to 
November 8, 2022. 
 You asked the Plan to pay for the home health services. You say that 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 22, 2022. The NOA was not received by the Plan until 
December 28, 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 October 22, 2022, to November 8, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 testing (81479) provided on March 26, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this test was medically necessary and was 
reported correctly. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
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. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have 
been met. Therefore, we decided that the Plan has to pay for Guardant360 testing (81479) provided on March 
26, 2021.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from January 17, 2022, to 
February 15, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
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 January 17, 2022. The NOA was not received by the Plan until March 10, 
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 January 17, 2022, to February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cibinqo. 
 
You asked the Plan to pre-approve the medication. You say that the requested medication is necessary for the 
enrollee's treatment. 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 Cibinqo.  
 
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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 You asked the Plan to pre-approve Injectafer. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Injectafer. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found based on the medical records provided 
there is no indication that the enrollee has tried and failed the required drugs. There is no documentation 
indicating that Ferrlecit or Infed would likely be less effective and/or likely have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99211 billed for date of service September 
26, 2022. 
 
You asked the Plan to pay for procedure code 99211. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says procedure code 99211 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 99211 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99211 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99211 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99211 billed for date of service September 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for contact lenses purchased on December 
8, 2022.  
You asked the Plan to pay an additional amount for contact lenses. You say that you should only have to pay 
$40. The Plan denied your request. The Plan says the allowable amount for the contact lenses is $200 which 
was paid by the Plan. The remaining $40 is your responsibility. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay an 
additional amount for contact lenses purchased on December 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test provided on December 14, 2022. 
 
You asked the Plan to pay for the Tempus xF test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF test have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF test provided on 
December 14, 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 you had a serious fall and are currently not back at 
your baseline and still require rehabilitation services. The Plan denied your request. The Plan says the 
requested services are 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 pre-approve 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 You do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services rendered on September 15, 2022. 
 
You asked the Plan to pay for the services. You say that this was denied as experimental in error. The Plan 
denied your request. The Plan says the denial of the comprehensive panel was appropriate.  
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the provided documentation does not clearly describe the enrollee with a condition where this testing 
would have directly impacted medical management. There was no description of what treatment changes would 
be considered based on the results that would be different than standard medication choosing methods or how it 
might lead to a better overall outcome for this enrollee. 
 
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 pay for laboratory services rendered on September 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 25, 2022, to June 
23, 2022. 
 You asked the Plan to pay for the home health services. You say that this claim was billed correctly. 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 May 25, 2022. The NOA was not received by the Plan until November 18, 
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 May 25, 2022, to June 23, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided on January 28, 
2023. 
 
You asked the Plan to pay for the outpatient 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 provider is not enrolled in 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided 
on January 28, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF test provided on December 12, 2022. 
 
You asked the Plan to pay for the Tempus xF test. You say that this test was medically necessary. The Plan 
denied your request. The Plan says this test is not FDA approved for use in the enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved. Based on this information, we decided that Medicare rules for coverage of the Tempus xF test have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xF test provided on 
December 12, 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 November 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement in place which indicates these tests should be included in the dialysis rate. 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 
November 9, 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 December 14, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that at this time, there is no 
contractual agreement which indicates these tests should be included in the dialysis rate. The Plan denied your 
request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colorectal cancer screening; fecal-occult blood test 
(G0328) provided December 21, 2022. 
 You asked the Plan to pay for the laboratory service. You say that you believe the second test was medically 
necessary. The Plan denied your request. The Plan says this service exceeds the benefit maximum. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
Though the Plan offers a colorectal cancer screening benefit, certain limitations apply. This test is only covered 
once every calendar year. The records show your benefit for the requested item or service was exhausted on 
date of service November 10, 2022. Therefore, we decided that the Plan does not have to pay for the colorectal 
cancer screening; fecal-occult blood test (G0328) provided December 21, 2022.