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

 
We decided that the Plan does not have to pay for the Tempus xF testing (81455) provided on April 24, 2023. 
 
You asked the Plan to pay for the Tempus xF testing. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this test has not had FDA approval or clearance as a companion in 
vitro diagnostic or an FDA-approved or cleared indication for use in this enrollee's cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers NGS testing, when 
the test is FDA approved or has clearance as a companion in vitro diagnostic. 
 
 
We looked at the file and Medicare rules. Research shows that the Tempus xF liquid biopsy is not FDA 
approved nor does it have clearance as a companion in vitro diagnostic. Based on this information, we decided that Medicare rules for coverage of the Tempus xF testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the Tempus xF testing (81455) provided on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481 and 87798 billed for date of service 
August 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that records were provided. The Plan denied your 
request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The file shows that a urinary tract infection panel was billed with CPT codes 87481 and 87798. The panel 
testing was not billed with a single code as required. 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 87481 and 87798 billed for date of service August 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the records do not show that it is medically necessary 
to be in an LTACH in place of an acute care hospital.  
 
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 that there is no documentation provided indicating medical necessity for admission to 
an LTACH. There are no services available at the LTACH that the enrollee requires that are not available at the 
health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an immediate maxillary partial denture (D5221). 
 
You asked the Plan to pre-approve D5221. You say that the enrollee needs this dental work. The Plan denied 
your request. The Plan says D5221 has been correctly denied. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers D5221 when 
the services are medically necessary and reasonable.  
 
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 D5221. Our reviewer says that D5221 
is not medically necessary. Our physician reviewer found the enrollee needs to follow up with her dental 
provider for timely treatment with implants, and the crowns. The enrollee has most of her teeth, which will 
allow her to chew and eat her food. There are other options that can keep teeth from potentially shifting into the place where crowns will be placed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of D5221 have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an immediate maxillary partial denture (D5221).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve a continuation of care with an OON provider. You say that the house-calls 
are medically necessary. You say that you have been seeing the enrollee since October of 2020, and ask for 
coverage due to continuity of care needs.  The Plan denied your request. The Plan says there are in-network 
providers within a reasonable distance from the enrollee's location that can provide virtual visits and/or accept 
house-calls. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 a continuation of care with an OON 
provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician 
reviewer found the records do not document that the enrollee is currently receiving any active treatment and/or 
medical management of their condition that makes it medically necessary to continue care with the OON 
provider as requested. There is nothing unique about the enrollee's condition that would make it medically 
necessary to continue care with the OON provider. The Plan has shown that they have in-network specialists 
who have the qualifications and expertise necessary to meet the current medical Standards of Care required for 
treatment of the enrollee's condition. The enrollee's medical management and/or follow-up care can be safely 
transitioned to an in-network specialist at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a continuation of care with an OON provider have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuation of care with an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a heavy-duty rollator (E1399) to be purchased through a 
provider that is not certified in Medicare. 
 
You asked the Plan to pay for a heavy-duty rollator. You say that the item is medically necessary The Plan 
denied your request. The Plan says the provider is not certified with Medicare. 
 
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 a heavy-duty rollator (E1399) to be 
purchased through a provider that is not certified in Medicare.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 for date of service June 15, 2023, to 
June 17, 2023. 
 
You asked the Plan to pay for procedure code 99291. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted medical 
records include evaluation and management note; however, the evaluation and management does not include 
the actual dates of service. Based on this information, we decided that Medicare rules for coverage of 
procedure code 99291 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 for date of service June 15, 2023, to June 17, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950) for tooth #29. 
 
You asked the Plan to pre-approve the dental services. You say that there is a wide gap causing decay, so a new 
crown and core buildup is necessary. The Plan denied your request. The Plan says that the denial of 
authorization for these services is correct because the intraoral photograph shows there is an existing crown on 
tooth #29 which appears unremarkable. There has been no radiograph provided for review to support that this 
crown is failing. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable. 
 
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 dental services. Our reviewer says 
that the crown (D2740) and core buildup (D2950) for tooth #29 is medically necessary. Our physician reviewer 
found that the documentation indicates the presence of a crown in place on tooth #29. The photograph and 
narrative indicate that there is an open margin with recurrent caries. It is medically reasonable and necessary to 
remove the current crown to remove the caries and restore with a core build up and new crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) and core buildup (D2950) for tooth #29.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transportation services provided on June 12, 
2023. 
 
You asked the Plan to pay for non-emergent transportation services. You say that the services were medically 
necessary due to the enrollees condition. The Plan denied your request. The Plan says the services were not 
medically necessary, and another form of transportation could have been used. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 non-emergent transportation services. Our 
physician reviewer found the services were not medically necessary due to the enrollee's condition. Our 
reviewer says that the enrollee was being discharged following their 5th day of symptoms, meaning they had 
completed the recommended isolation period per centers of disease control (CDC) guidelines. The enrollee 
appeared to be confused at their baseline and able to follow simple commands. Therefore, the enrollee did not 
require a higher level of care at the time of transport. Documentation also does not support that other means of 
transport were contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent transportation services have not been met. Therefore, we decided 
that the Plan does not have to pay for non-emergent transportation services provided on June 12, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that LTACH services are not medically necessary. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found that while the enrollee may be stable for a skilled nursing facility level of care, the 
documentation supports that the enrollee's conditions are too complex for the skilled nursing facilities in the 
area. The enrollee requires a higher level of care from an LTACH. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve LTACH 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service 
May 11, 2023. 
 
You asked the Plan to pay for procedure codes 99152 and 99153. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says codes 99152 and 99153 are not payable as billed. 
 
The Plan must follow Medicare rules say that providers must report services correctly. Providers must report 
services with the appropriate CPT code. The rules also say that a Professional Component (PC)/Technical 
Component (TC) Indicator of 3 means these are technical component only codes. This indicator identifies 
stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic 
tests for which there is an associated code that describes the professional component of the diagnostic-only 
tests. It also identifies codes that are covered only as diagnostic tests and therefore, do not have a related 
professional code. The total RVUs for technical component only codes include values for practice expense and 
malpractice expense only. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical records do not 
indicate the presence of an independent trained observer for the billed services; therefore, code 99152 is not 
supported. The records indicate that this service was provided to the enrollee while an outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 3 for CPT code 99153. This means there 
is only a technical component for the CPT code. This code is not payable as billed. Based on this information, 
we decided that Medicare rules for coverage of procedure code 99152 and 99153 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99152 and 99153 billed for date of service 
May 11, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 70 trips for routine transportation. 
 
You asked the Plan to pre-approve additional transportation.. The Plan denied your request. The Plan says you 
benefit only allows 60 trips for this service. 
 
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 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional 70 trips for routine transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 20, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan.  The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan 
to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory 
services provided on March 20, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on March 4, 2023.  
 You asked the Plan to pay for the anesthesia services. You say that the services are a covered benefit. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 3, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on March 4, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Quest HBA1/HBA2 (alpha globin 1 and alpha 
globin 2) gene testing (81257). 
 
You asked the Plan to pre-approve the genetic testing. You say that you really need the blood test done to rule 
out having this disease. The Plan denied your request. The Plan says the requested test is not an approved test. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on the diagnostic program, MolDX Technical Assessment, the 
requested test is not an approved test. Based on this information, we decided that Medicare rules for coverage 
of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the 
Quest HBA1/HBA2 (alpha globin 1 and alpha globin 2) gene testing (81257).
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 the enrollee's recovery is dependent on this 
treatment. You say that the enrollee requires intensive inpatient rehabilitation with daily physician 
management, 24-hour specialized rehab nursing , and intensive physical and occupational therapy to optimize 
mobility and strength. The Plan denied your request. The Plan says an IRF admission is not medically 
necessary.  
 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 that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a ultrasound provided on November 15, 
2022. 
 
You asked the Plan to waive the copayment for a ultrasound. You say that you disagree with the copayment. 
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 a $165 
copayment for outpatient diagnostic tests/Medicare coveredradiological diagnosticservices. 
 
You have been asked to pay a $165 copayment for a ultrasound. This item/service falls within the outpatient 
diagnostic tests/Medicare coveredradiological diagnosticservices 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. However, since the 
allowed amount is less than the standard copayment, you only owe $136.51. Therefore, we decided that the 
Plan does not have to waive the copayment for a ultrasound provided on November 15, 2022.