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

 
We decided that the Plan does not have to pre-approve the Genomic Unity Exome Plus Analysis (0214U) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the Genomic Unity Exome Plus Analysis. You say that while other 
laboratories may be able to sequence the same genes, clinically significant variants are innately missed when 
not analyzed using whole genome sequencing as the underlying technology. The Plan denied your request. The 
Plan says in-network providers can provide the genetic services needed. 
 
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 the Genomic Unity Exome Plus 
Analysis. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
requested test is available in network. The review has determined that the genetic testing is not medically 
necessary to be performed at the OON provider instead of at an in-network provider. 
 
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 Genomic Unity Exome Plus Analysis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Genomic Unity Exome Plus Analysis (0214U) to be 
provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided on April 6, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you needed a permanent denture. The Plan 
denied your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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 record 
shows your benefit for the requested item or service was exhausted on date of service August 3, 2022. 
Therefore, we decided that the Plan does not have to pay for a complete mandibular denture (D5120) provided 
on April 6, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing provided on June 7, 2022, billed with codes 83735 and 
84443. 
 
You asked the Plan to pay for the lab testing. You say that the records support this testing.  The Plan denied 
your request. The Plan says that there was an order in the file; however, this does not include an order date. 
Therefore, this testing cannot be covered.  
 
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. The Plan has not provided a valid denial rationale in this case. The only rationale 
given was that the order in the file was not dated. However, review of the requisition shows that the collection 
date was June 7, 2022. This matches the collection date documented on the lab report. Without a valid 
rationale, we find that the denial of payment for these services is not supported.  Therefore, we decided that the 
Plan has to pay for the lab testing provided on June 7, 2022, billed with codes 83735 and 84443.  
 
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: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99291, 92950 and 31500. 
We decided that the Plan does not have to pay for the services described by procedure code(s) 93042.  
 
You asked the Plan to pay for practitioner services provided on April 20, 2023, billed with procedure codes 
93042, 99291, 92950 and 31500. You say that the claim is billed correctly and should be paid. The Plan says 
that payment for code 93042 is bundled into payment for another code. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99291, 92950 and 
31500.  
 
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 did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported.  Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99291, 92950 and 31500.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93042. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file, and Medicare rules. We have confirmed that code 93042 is a column two code to column 
one code 99291 with a modifier indicator of 0. The column two code is therefore not payable. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 93042 
have not been met. Therefore, we decided that the Plan does not have to pay for the services described by 
procedure code(s) 93042. 
 
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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has 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 reconsideration as 
the enrollee currently meets full IRF criteria. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare guidelines for services in an inpatient rehabilitation facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for an 
IRF admission, as best summarized by the physician's appeal letter from October 20, 2023. The enrollee's 
condition is in fact complex and fragile, and there is every reason to expect that they will participate in and 
benefit from services to include at minimum physical and occupational therapy, a nutritionist, physician 
oversight of polypharmacy, and case manager coordination of any additional services that might be needed to 
make a sustainable return home as well as avoid further preventable readmissions to the acute hospital. 
Therefore, the enrollee's needs cannot be met in a lower level of care and the requested inpatient rehabilitation 
facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from August 22, 2022, to 
August 23, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you are requesting a review of the 
medical records for medical necessity of an inpatient stay and approval of the services provided. The Plan 
denied your request. The Plan says that the medical records submitted with the appeal do not support a 
reasonable expectation that the enrollee would require acute hospital care extending beyond 2 midnights. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee has a history of chronic obstructive pulmonary disease, diabetes, hyperlipidemia, 
hypertension, and atrial fibrillation who presented to the Emergency Department (ED) on August 21, 2022, 
with complaints of shortness of breath. The enrollee also reported palpitations. The review has determined that 
the record showed that at the time of inpatient admission it was reasonable for the admitting physician to 
expect that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights with supporting documentation of the enrollees history and comorbidities, signs and symptoms, 
current medical needs, and risk of an adverse event. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 22, 2022, to August 23, 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: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection polymerase chain reaction (PCR) panel 
provided on October 20, 2022, and billed with codes 87481, 87798, and 87801. 
 
You asked the Plan to pay for the fungal infection PCR panel. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the fungal infection PCR panel have not 
been met. Therefore, we decided that the Plan does not have to pay for the fungal infection polymerase chain 
reaction (PCR) panel provided on October 20, 2022, and billed with codes 87481, 87798, and 87801.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve the home infusion therapy (S9328) provided from May 21, 2023, 
through June 17, 2023. 
 
You asked the Plan to pre-approve the services. You say that please refer to the authorization number, granting 
a waiver and approving codes S9328, 99601, 99602, 62368 and 62329 for this provider. The Plan denied your 
request. The Plan says that this code is not used for Medicare purposes. 
 
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 authorization provided by the Plan did approve 
S9328. Therefore, we decided that the Plan has to pre-approve the home infusion therapy (S9328) provided 
from May 21, 2023, through June 17, 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 drug testing provided on April 27, 2023. 
 
You asked the Plan to pay for the drug testing. You say that you have included evidence showing medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the drug testing 
provided on April 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavior health services provided on April 26, 2023, to May 
2, 2023. 
 
You asked the Plan to pay for behavior health services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this provider type is not eligible in the Medicare 
program. 
 
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselor is among the 
provider types that are not eligible to enroll in Medicare and to receive payment for covered items or services 
from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare 
program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of behavior health services have not been met. Therefore, we decided that the Plan does not have 
to pay for behavior health services provided on April 26, 2023, to May 2, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88342 and 88341 billed for date of service 
May 17, 2023. 
 
You asked the Plan to pay for procedure codes 88342 and 88341. You say that the claim should be paid as 
billed.  The Plan denied your request. The Plan says payment for code 88342 is bundled into payment for code 
88189. 
 
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, we have confirmed that code 88342 is a column II code to column I code 88189. This claim has 
not been billed with an appropriate modifier to bypass the edit. As 88341 is an add-on code to primary code 
88342, this also cannot be paid as the primary code is not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 
88342 and 88341 billed for date of service May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture 
(D5110/D5120) and an unspecified preventive procedure (D1330) provided on May 26, 2023. 
 
You asked the Plan to pay for D5110, D5120 and D1330. You say that the enrollee has not had dental work in 
10 years, and you are in a lot of pain. The Plan denied your request. The Plan says the rendered dental services 
are not covered dental benefits. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110/D5120) and an unspecified preventive procedure (D1330) 
provided on May 26, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation not skilled nursing. 
You say you received abusive treatment at skilled nursing. The Plan denied your request. The Plan says the IRF 
services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the medical record overall significantly complies with the various documentation requirements for an 
IRF admission, as best summarized by the physiatry evaluation  from October 18, 2023. Your condition is in 
fact complex and fragile, and there is every reason to expect that you will participate in and benefit from IRF-
level services to include at minimum physical, occupational and speech therapy, neuropsychology services, 
recreational therapy, physician oversight of polypharmacy and case manager coordination of any additional 
services and outpatient appointments that might be needed to make a sustainable return home, as well as avoid 
preventable readmissions to the acute hospital. Therefore, your needs cannot be met in a lower level of care and 
the requested inpatient rehabilitation facility admission is approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and a full mouth scaling root 
planing (D4346) provided on July 31, 2023. 
 
You asked the Plan to pay for D4921 and D4346. You say that you were unaware this was not covered. The 
Plan denied your request. The Plan says the rendered dental services are not covered dental benefits. 
 
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) and a full mouth scaling root planing (D4346) provided on July 31, 2023.