Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department and related services received on September 
9, 2022, to September 10, 2022. 
 
You asked the Plan to pay for the emergency department and related services. You say that you would like 
reimbursement. The Plan denied your request. The Plan says that the services received are not payable. 
 
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. Review of the file shows that the Plan did not provide an explanation or 
Medicare rules on why this claim was denied. The Plan did not substantiate their denial. Therefore, we decided 
that the Plan has to pay for the emergency department and related services received on September 9, 2022, to 
September 10, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services on February 19, 2023, through March 
20, 2023. 
 
You asked the Plan to pay for home health services. You say that you would like to request reconsideration of 
the denied claim. 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 February 19, 2023. The NOA was not received by the Plan until April 7, 
2023. 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 on 
February 19, 2023, through March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BRCA genetic testing rendered on January 9, 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 criteria for coverage are not met. 
 
The Plan must follow Medicare rules. The rules say that the patient must have a diagnosis of cancer for 
coverage eligibility of hereditary germline testing. 
 
We looked at the file and Medicare rules. The file shows that the enrollee does not have a personal history of 
cancer. 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 pay for the BRCA genetic testing rendered on 
January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 23, 2023, billed 
with procedure codes 99204, 74230, 72040, 70100, 70310, 71045, and 74240.  
 
You asked the Plan to pay for the radiological services provided. You say that the claim was billed correctly 
and should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiological services provided have not been met. The service provided is a barium swallow 
study and includes the administration of a substance to the patient. As such, this is a non-covered service. 
Therefore, we decided that the Plan does not have to pay for radiological services provided on January 23, 
2023, billed with procedure codes 99204, 74230, 72040, 70100, 70310, 71045, and 74240.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve replacement of permanent implantable defibrillator 
system (33249). 
 
You asked the Plan to pre-approve replacement of permanent implantable defibrillator system. 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. 
 
The Plan follows Medicare rules. Medicare rules say that patients with an existing ICD may receive an ICD 
replacement if it is required due to the end of battery life, ERI, or device/lead malfunction. 
 
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 replacement of permanent implantable 
defibrillator system. Our reviewer says that the services are not medically necessary. Our physician reviewer 
found guidelines would not support the replacement of the current ICD with a biventricular ICD. In summary, 
there is insufficient documentation to support the medical necessity for removal of the current defibrillator and 
replacement with a bi-ventricular pacemaker or defibrillator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement of permanent implantable defibrillator system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve replacement of permanent implantable 
defibrillator system (33249).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Wegovy. 
 
You asked the Plan to pre-approve Wegovy. 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 Wegovy.   
Benefits for Wegovy 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 15, 2022. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. 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 December 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 36246-LT-GZ billed for date of service September 2, 
2022. 
 
You asked the Plan to pay for code 36246-LT-GZ. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says this claim line cannot be paid because it was billed with 
the GZ modifier. 
 The Plan must follow Medicare rules. Medicare rules say that claim lines billed with the GZ modifier will be 
automatically denied and no further medical review can occur. 
 
In this case, the claim line in dispute was billed with a GZ modifier, so it cannot be paid. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 36246-LT-GZ have not been met. Therefore, we decided that the Plan does not have to pay 
for code 36246-LT-GZ billed for date of service September 2, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 28, 2022, to 
July 26, 2022. 
 
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 there are no orders to support the billed visits. 
 
The Plan must follow Medicare rules. The rules say that HHAs may not submit a claim until after all services 
are provided for the period and the physician has signed the plan of care and any subsequent verbal order.  
 
We looked at the file and Medicare rules. The file shows that there is no valid order for the dates of service at 
issue. 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 pay for the home health services rendered from June 
28, 2022, to July 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting an expedited appeal for the denial 
of an IRF admission. You say the enrollee is being evaluated for rotator cuff repair and needs additional 
therapy. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an 
acute 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on February 28, 2022. 
 
You asked the Plan to pay for the anesthesia services. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says you billed these services with an incorrect POS 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 22.  However, the documentation shows that 
the patient was in an inpatient status on the date of service.  As a result, POS code 21 should have been used on 
the claim instead. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay 
for anesthesia services provided on February 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you require therapy in a SNF setting in order to 
return home at your prior level functioning with a decreased risk for readmission. The Plan denied your 
request. The Plan says the request is 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 that you do not have skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have 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 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 SNF care.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on March 30, 2022. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. The Plan denied 
your request. The Plan says that this service was not medically necessary based on the diagnoses of 
hyperglycemia and dehydration. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same 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 pay for the emergency ambulance transportation and ground mileage. Our reviewer says that transportation 
via ambulance to the emergency department was medically necessary. Our physician reviewer found you did 
require the expertise of trained personnel or the equipment available only on an ambulance in order to 
effectuate a safe transport. Transportation could not have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering your condition. Our reviewer also found that a prudent 
layperson would believe that immediate medical attention was required because you had weakness, 
hypertension, and hyperglycemia. 
 
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 emergency ambulance transportation and ground mileage have been met. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on March 30, 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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 81201, 81292, 81162 and 81307 billed for date of 
service February 10, 2023. 
 
You asked the Plan to pay for procedure codes 81201, 81292, 81162 and 81307. You say that you have billed 
the services at issue correctly. The Plan denied your request. The Plan says that rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's denial states that the claim was reported without a CLIA 
number for the rendering laboratory. Our review of the claim shows that a valid CLIA number was reported for 
the rendering provider. It is the Plan's responsibility to support its denial with evidence. In this case, the Plan 
has not supported its denial, so we must find in your favor. Therefore, we decided that the Plan has to pay for 
procedure codes 81201, 81292, 81162 and 81307 billed for date of service February 10, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on March 13, 2023. 
 
You asked the Plan to pay for the panel. 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 A provider/supplier shall not report multiple 
HCPCS/CPT codes if a single HCPCS/CPT code exists that describes the services. This type of unbundling is 
incorrect coding.  
 
We looked at the file and Medicare rules. The lab panel in this case was billed with multiple unbundled codes. 
Per Medicare rules, the panel should be billed with a single code. Based on this information, we decided that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have 
to pay for the lab panel provided on March 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme CGP Panel testing 
provided on February 12, 2023. 
 
You asked the Plan to pay for the Tempus xT Solid Tumor & Heme CGP Panel testing. You say that this 
testing was medically necessary.  The Plan denied your request. The Plan says this test is not FDA approved for 
use in the enrollee's cancer and prior authorization was not obtain for out-of-network services. 
 
The Plan must follow Medicare rules. Medicare rules say that that Medicare nationally covers NGS testing, 
when the test is is used for an FDA-approved or -cleared indication for use in the patient's cancer. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA approved for use in the enrollee's cancer. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Solid Tumor & Heme CGP Panel testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Tempus xT Solid Tumor & Heme CGP Panel testing provided on 
February 12, 2023.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the rationale for denial is not supported in the supplied records. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a medical eye examination provided on 
December 6, 2022. 
 
You asked the Plan to waive the coinsurance for a medical eye examination. You say that you were told before 
having the procedure that it was completely covered by 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 40% 
coinsurance for out-of-network glaucoma screenings, Medicare-covered eyeglasses or contact lenses after 
cataract surgery, annual diabetic retinopathy screening, and each Medicare-covered exam to diagnose and treat 
diseases or conditions of the eye.  
 
You have been asked to pay $50 in coinsurance, which is 40% of the allowed amount for a medical eye 
examination ($125 x 40% = $50). This item/service falls within the out-of-network glaucoma screenings, 
Medicare-covered eyeglasses or contact lenses after cataract surgery, annual diabetic retinopathy screening, and 
each Medicare-covered exam to diagnose and treat diseases or conditions of the eye benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for a medical eye examination provided on December 6, 2022.