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

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
December 30, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says in 
order to process this claim the Plan needs an Explanation of Benefit (EOB) from the primary insurer. The Plan 
made outreach but the primary insurer stated they do not have an EOB on file with the date of service 
December 30, 2022. 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has made 
outreach to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the 
emergency department visit until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for an emergency department visit provided on December 30, 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 the enrollee is ready to step down from a LTACH to 
IRF, this is medically necessary and meets all criteria. The Plan denied your request. The Plan says the 
complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 13, 2022, to 
March 12, 2022. 
 
You asked the Plan to pay for the home health services. You say that you were told that you could appeal this 
claim in an effort to receive payment. The Plan denied your request. The Plan says you did not supply medical 
records to show the medical necessity of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the home health services have been 
met. Specifically, the Plan sent you seven separate requests for medical records, and you have not responded to 
any of these requests.  Without medical records, we cannot determine if the services were medically necessary 
or billed appropriately. Therefore, we decided that the Plan does not have to pay for home health services 
provided from February 13, 2022, to March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for proprietary laboratory analyses provided on 
December 28, 2022. 
 
You asked the Plan to pay for proprietary laboratory analyses. You say that the services were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not requested. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for proprietary laboratory analyses provided on December 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing procedures (81225, 841226) provided on 
October 3, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the services at issue cannot be determined to be 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment.  
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of genetic testing have been met. 
Specifically, medical records supporting the necessity of the services at issue have not been provided. 
Therefore, we decided that the Plan does not have to pay for genetic testing procedures (81225, 841226) 
provided on October 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's continuation of care. 
 The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current setting. 
 
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 the record indicates that the enrollee has ongoing acute medical issues and still 
requires acute care services. The enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that they not currently receiving 
but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on January 16, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on January 
16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is medically necessary as the 
enrollee is at risk of hospitalization. The Plan denied your request. The Plan says the request is not medically 
necessary because the records show that the ordered settings for the noninvasive ventilator can be delivered by 
a bi-level PAP machine with AVAPS capability. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has diagnoses of COPD, 
obstructive sleep apnea, severe obesity, HFpEF, and obesity hypoventilation syndrome.  The patient was 
recently hospitalized and ABG was consistent with acute on chronic hypercarbic respiratory failure.  The 
patient improved with diuresis and noninvasive ventilation.  There are no pulmonary function tests to document 
the severity of the COPD.  There is no diagnosis of thoracic restrictive disease or neuromuscular disease.  
There is no ABG done while stable to document chronic CO2 retention.  If that is present, the patient may 
benefit from BiPAP with AVAPS during sleep as an outpatient.  Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the definitive drug testing of 22 or more classes (G0483) provided on 
October 26, 2022. 
 
You asked the Plan to pay for the definitive drug testing of 22 or more classes. The Plan denied your request. 
The Plan says that this testing was not billed correctly. 
 
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 G0483 is the definitive drug testing of 22 or more classes. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, we reviewed the records and 
found that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules 
for coverage of the definitive drug testing of 22 or more classes have been met. Therefore, we decided that the 
Plan has to pay for the definitive drug testing of 22 or more classes (G0483) provided on October 26, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LAAC. 
 
You asked the Plan to pre-approve LAAC. You say that the requested LAAC is medically necessary. The Plan 
denied your request. The Plan says he requested LAAC does not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare 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 pre-approve LAAC. Our reviewer says that the 
requested LAAC is not considered medically necessary in this case. Our physician reviewer found that at issue 
is the medical necessity of implanting a LAAC device in this enrollee in whom there is elevated risk of 
thromboembolic stroke due to atrial fibrillation and elevated CHADS2VASC score. There is also an increased 
risk of bleeding. While there is reference to consideration of the LAAC, there is no documentation of 
performance of an evidence-based shared decision-making interaction on anticoagulation. As such, guidelines 
would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be 
considered reasonable or medically necessary in this patients clinical management. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC have not been met. Therefore, we decided that the Plan does not have to 
pre-approve LAAC.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gastrointestinal pathogens panel provided on October 27, 
2022, and billed with codes 87500, 87505, 87491 and 87493. 
 
You asked the Plan to pay for a gastrointestinal pathogens panel. You say that the services at issue were a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a gastrointestinal pathogens panel have not been met. Specifically, the laboratory panel at issue 
was reported with multiple procedure codes. Therefore, we decided that the Plan does not have to pay for a gastrointestinal pathogens panel provided on October 27, 2022, and billed with codes 87500, 87505, 87491 and 
87493.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for debridement of nails provided on January 3, 2023. 
 
You asked the Plan to pay for debridement of nails. You say that you cannot safely trim your toenails as you 
were involved in an accident and had four fingers amputated on your dominant hand. You say that you were 
having pain in your toes and the foot care has made walking more comfortable. The Plan denied your request. 
The Plan says routine foot care is statutorily excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of 
debridement of nails have not been met. Therefore, we decided that the Plan does not have to pay for 
debridement of nails provided on January 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service January 1, 
2023, to January 28, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that this service was medically necessary and the 
ordering physician was in-network. The Plan denied your request. The Plan says the billed code is invalid for 
Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code.  
We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service January 1, 2023, to January 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the residence visit for established patient and nail 
debridement provided on January 10, 2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 in this case is not a network provider with the Plan. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the residence visit for established patient and nail debridement provided on 
January 10, 2023, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee to receive specialized recovery care and to prevent readmission to a short-term care hospital. The 
Plan denied your request. The Plan says the enrollee's records do not show that they need continued treatments 
and care that can only be given in a hospital setting. 
 
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 the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wig (A9282) purchased on July 28, 2022. 
 
You asked the Plan to pay for a wig. You say that the enrollee lost hair due to chemotherapy. The Plan denied 
your request. The Plan says this item is not covered because it is not primarily medical in nature. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for a wig (A9282) 
purchased on July 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 30, 2022. 
 
You asked the Plan to pay for the lab services. You say that the laboratory testing was medically necessary and 
billed correctly. 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 November 30, 2022.