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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
7, 2022, to September 20, 2022. 
 
You asked the Plan to pay for SNF care. You say that the services were medically necessary due to a 
significant decline in overall function ability. The Plan denied your request. The Plan says the SNF services 
you are requesting do not meet the requirements for approval. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did 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 pay for skilled nursing facility (SNF) care provided from September 7, 2022, to September 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG+ assay panel (81317, 81292, 81298, 81295, 
81294 and 81297) provided on December 12, 2022.  
You asked the Plan to pay for the laboratory services. You say that reconsider the determination and cover the 
Tempus xG+ assay for Extended Hereditary Cancers-Gene panel test at the in-network benefit level. The Plan 
denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. It is not appropriate to bill individual CPT codes for a single panel. If a laboratory assays 2 or more 
genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel 
constitutes a single procedural service, so one (1) Healthcare Common Procedure Coding System (HCPCS) 
code must be submitted for the panel. Medicare says if a single procedure is performed, only one code with one 
unit of service may be reported for the procedure. Therefore, we decided that the Plan does not have to pay for 
the Tempus xG+ assay panel (81317, 81292, 81298, 81295, 81294 and 81297) provided on December 12, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 06, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 06, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425 and A0428) provided on 
December 9, 2022. 
 
You asked the Plan to pay for the services. You say that the claim was billed correctly. The Plan denied your 
request. The Plan says the diagnosis code billed is not accepted as a primary diagnosis. 
 
Review of the file shows that diagnosis code R65.21 has a code first note and is not acceptable as a primary 
diagnosis. 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 the ambulance services (A0425 and A0428) 
provided on December 9, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care provided from November 1, 
2022, to November 21, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that you were required to stay and 
quarantine for an additional 10 days because you tested positive for Covid-19 while in the facility. 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 $0 
copayment for days 1 to 20 and a $100 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $500 for SNF care ($100 per day x 5 days = $500). This item/service falls within 
the SNF care 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 copayment for SNF care provided from 
November 1, 2022, to November 21, 2022.  
 
Your complaint about being required to quarantine due to testing positive for Covid-19 is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile water (A4216) and gauze (A6216) provided on 
December 23, 2022. 
 
You asked the Plan to pay for the items. You say that you are asking the Health Plan to review medical records 
and process claim based on medical necessity. The Plan denied your request. The Plan says the items are not 
covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The requested items, which 
were used to clean the wound, are non-covered per the LCD. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pay for the sterile water (A4216) and gauze (A6216) provided on December 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 
9, 2023. 
 
You asked the Plan to pay for the Tempus xF liquid biopsy. 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. 
 
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 liquid biopsy have not been met. Therefore, we decided that 
the Plan does not have to pay for the Tempus xF liquid biopsy (81455) provided on February 9, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 
24, 2022, to October 23, 2022. 
 You asked the Plan to pay for SNF care. You say that the services were medically necessary for the enrollee's 
care. The Plan denied your request. The Plan says the enrollee did not require skilled services on a daily basis.  
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing 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 pay for skilled nursing facility (SNF) care provided from September 24, 2022, to October 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the long-term electroencephalogram (EEG) monitoring 
services (95720) provided on July 22, 2022, by an out-of-network (OON) provider.  
 You asked the Plan to pay for the monitoring services. You say that the services were medically necessary and 
therefore payable. The Plan denied your request. The Plan says this service is considered not medically 
necessary, experimental or investigational and excluded from coverage. 
 
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 long-term electroencephalogram (EEG) 
monitoring services (95720) provided on July 22, 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 telehealth services provided on March 20, 2023. 
 
You asked the Plan to pay for telehealth services. You say that the records provided support the services. 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 telehealth services 
provided on March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skin barrier (A5120-AU x50), foam dressing (A6212-A1 x1) 
and gauze (A6216-AW x200) provided on January 20, 2023. 
 
You asked the Plan to pay for the items. You say that you are asking the Health Plan to review medical records 
and process claim based on medical necessity. The Plan denied your request. The Plan says the enrollee does 
not have an ostomy and there is no documentation of use of this skin barrier in the wound care note. The Plan 
states the wound care note does not document use of a foam dressing. 
 
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 items. Our physician reviewer found the 
foam dressing (A6212) is addressed in LCA A54563: A foam dressing (A6209, A6210, A6211, A6212, A6213, 
A6214, A6215) is a sterile, non- linting, absorptive dressing which is made of open cell, medical grade 
expanded polymer. It has a non-adherent property over the wound site. The wound care note does not 
document use of a foam dressing. The review has determined that for code A5120, the medical records 
provided did not meet the requirements listed in the LCD for Medicare coverage. Furthermore, the requested 
item (A6212), which was used to clean the wound, is non-covered per the LCD. 
 
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 items have not been met. Therefore, we decided that the Plan does not have 
to pay for skin barrier (A5120-AU x50), foam dressing (A6212-A1 x1) and gauze (A6216-AW x200) provided 
on January 20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on March 9, 2021, to April 1, 
2021. 
 
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the time 
limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until March 27, 2023. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for home health services provided on March 9, 2021, to April 1, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 27, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the records provided support the services. 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 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Omnipod insulin administration system. 
 
You asked the Plan to pre-approve Omnipod. You say that Omnipod is a medical necessity for the enrollee. 
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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Omnipod 
insulin administration system.  
 
Benefits for Omnipod 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cozaar. 
 
You asked the Plan to pre-approve Cozaar. You say that the enrollee was taking the generic version of the 
medication and their blood pressure increased to 160/100. 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 Cozaar.  
 
Benefits for Cozaar 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) provided on January 27, 
2023. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI). You say that you are appealing the claim 
payment denial. 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 magnetic resonance 
imaging (MRI) provided on January 27, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from August 4, 2022, 
through August 17, 2022. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the home health services have not been met. The first home health 
visit reported was August 4, 2022, but there is not a Q-code provided to say where the service was performed. A required Q code to report where home health services was not billed on this claim. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from August 4, 2022, through August 
17, 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 the enrollee needs more physical therapy and 
occupational therapy. You also say the enrollee cannot walk on their own and is not independent enough to go 
home. The Plan denied your request. The Plan says the SNF services requested do not meet the requirements 
for approval.  
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) for teeth 
numbers 30, 31, 20, and bone graft at time of implant placement (D6104) for teeth numbers 30, 31, 20. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says has previously approved the surgical placement of an implant 
body (D6010) for teeth numbers 19 and 29, which makes this benefit already exhausted. The Plan also says that 
the bone graft at time of implant placement (D6104) is also denied because it coincides with the other service.  
 
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. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan 
rules say that this benefit includes the surgical placement of implant body (D6010) but is limited to two every 
calendar year; 1 per tooth every 5 calendar year. The record shows your benefit for the requested item or 
service was exhausted with the prior approval for the surgical placement of an implant body (D6010) for teeth 
numbers 19 and 29. The record also shows that the bone graft at time of implant placement (D6104) is tied with 
the other service. Therefore, we decided that the Plan does not have to pre-approve surgical placement of 
implant body (D6010) for teeth numbers 30, 31, 20, and bone graft at time of implant placement (D6104) for 
teeth numbers 30, 31, 20.