Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
rendered July 17, 2020, to August 1, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you received skilled nursing 
care in the past and were not charged a copayment. The Plan denied your request. The Plan says the copayment 
applied correctly in this case. 
 
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 $20 
copayment per day for days 1-20 of a benefit period for skilled nursing facility care.  
 
You have been asked to pay a total cost share of $300 for the 15 days of SNF services ($20 x 15). The services 
provided fall within the skilled nursing facility 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 the skilled nursing facility (SNF) services rendered July 17, 2020, to August 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on August 3, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that your copayment should 
only be $180. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $270 
copayment for outpatient surgery/in-network/outpatient hospital.  
 
You have been asked to pay a $270 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/in-network/outpatient hospital 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 an outpatient surgery provided by a participating provider on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 7, 2020, by an out-
of-network provider. 
 
You asked the Plan to pay for the medical services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says you self-referred to an out-of-network provider 
and you do not have out-of-network benefits. 
 
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 has network providers 
available who can provide 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 medical services provided on January 7, 2020, 
by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT). 
 
You asked the Plan to pre-approve the HBOT. You say that the records provided support the need for HBOT. 
The Plan denied your request. The Plan says the information provided did not establish the medical necessity of 
HBOT. 
 
The Plan follows Medicare rules. Medicare rules say that HBOT is covered for diabetic wounds of the lower 
extremities in patients who meet specific coverage criteria. 
 
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 HBOT. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee is currently seeing wound 
care and very slow healing. An exam showed pulses diminished in BLE which was present w/Doppler dp/pt, 
LLE wound. A wound care assessment from November 24, 2020 showed that wound #2 on the left, distal, 
medial lower leg is an arterial ulcer and has received a status of not healed. Subsequent wound encounter 
measurements are 0.5cm length x 0.3 cm width x 0.2 cm depth, with an area of 0.15 sq cm and a volume of 
0.03 cubic cm. There was no drainage noted. The wound bed has 81-100% Epithelialization, and 
nogranulation. The wound is improving. The periwound skin exhibited edema, callus, dry/scaly, and 
Hemosiderosis. The periwound skin does not exhibit signs or symptoms of infection. The wound was debrided. 
The wound care orders included local wound care 2 times weekly, compression/ edema control 2 times weekly 
and prn, offloading, elevation, and an Unna boot. A wound care assessment from October 14, 2020 showed 
wound #2 left, distal, medial lower leg is a venous ulcer and has received a status of not healed. There was no 
drainage noted. Wound bed has 8l-100% Epithelization, no granulation. The wound is improving. The 
periwound skin exhibited edema, callus, dry/scaly, Hemosiderosis. The periwound skin did not exhibit signs or 
symptoms of infection. Wound care assessment on September 23, 2020 showed wound #2 left, distal, medial 
lower leg is a venous ulcer and has received a status of not healed. There was no drainage noted. Wound bed 
has 8l-100% Epithelialization, and nogranulation. The periwound skin color is normal. The periwound skin 
exhibited edema, callus, and dry/scaly. Our physician reviewer found that the requested HBOT in this case is 
not medically reasonable and necessary. 
 
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 HBOT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy (HBOT).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 29, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided on July 29, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20610, 99152, 77002) provided on June 10, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot 
be verified. 
 
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 asked our coding 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 services. Our reviewer says that the use 
of CPT codes 20610 and 99152 is not supported by the records provided. Our coding reviewer found that the 
documentation submitted is illegible and unable to review. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT 20610 and 99152 have not been met. Additionally, CPT 77002 is an add-
on code. As the primary procedure code is not payable, the add-on code is also not payable. Therefore, we 
decided that the Plan does not have to pay for the services (20610, 99152, 77002) provided on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lipid panel (CPT Code 80061) and thyroid stimulating 
hormone (84443) provided on December 10, 2019. 
 
You asked the Plan to pre-approve the laboratory services. You say that your provider ordered these tests for 
you as part of your preventative physical. You state you should not be responsible for these charges as you had 
no idea these would not be covered based on the way the codes are being billed. The Plan denied your request. 
The Plan says the services are not payable by Medicare. 
 
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 this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. It is not appropriate to bill Medicare for services that are 
not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, 
use the appropriate modifier. Compliance with the provisions in this policy may be monitored and addressed 
through post payment data analysis and subsequent medical review audits. Therefore, we decided that the Plan 
does not have to pre-approve lipid panel (CPT Code 80061) and thyroid stimulating hormone (84443) provided 
on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
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 based on the documentation provided, the health plan's denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to 
perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care 
needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that there is no clinical advantage of LTACH over acute 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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The enrollee is 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BRCA testing provided on August 26, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you stated that you called customer service on August 14, 2020 and stated 
you were told prior authorization was required. The Plan states you indicated the appointment had already been 
scheduled. The Plan states that you specifically indicated you requested the test due to family history.   
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for BRCA testing. Based on the 
medical records provided, you did not meet the required criteria at the time of testing. The records show you 
did not follow the Plan contract rules in obtaining this service. Therefore, we decided that the Plan does not 
have to pay for BRCA testing provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on August 21, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim submitted did not have a valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and medical records to support the services billed.  
In this case, the records submitted do not contain a valid physician order. Medicare rules for coverage of this 
service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided 
to the enrollee on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 has network providers 
available who can provide 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 medical services provided  
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 his patient would benefit from LTACH 
care. The Plan denied your request. The Plan says there would be no clinically meaningful benefit to transfer to 
an LTACH. 
 
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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. In this case, ongoing care needs include tracheostomy care, surveillance laboratory studies, 
abdominal wound care, tube feeding, and therapy services. 
 
The documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH 
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 
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 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 Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on July 7, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX and 
it is a test not currently described by any existing CPT code. 
 
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 find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 7, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve catheter, transluminal angioplasty, drug-coated, non-laser coded 
C2623 provided on April 24, 2020. 
 
You asked the Plan to pre-approve catheter, transluminal angioplasty, drug-coated, non-laser. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested 
services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 catheter, transluminal angioplasty, 
drug-coated, non-laser. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee had a nonhealing ulcer of the 
right leg. Per the documentation, the enrollee was admitted April 24, 2020 and underwent recanalization of the 
right distal superficial femoral artery and popliteal artery, had an atherectomy/stent placement and drug coated 
balloon angioplasty. The enrollee had bilateral peripheral arterial disease with moderate disease in the left 
superficial femoral artery. The review has determined that the requested Catheter, transluminal angioplasty, 
drug-coated, non-laser  coded C2623 provided on April 24, 2020 was medically necessary and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of catheter, transluminal angioplasty, drug-coated, non-laser have been met. 
Therefore, we decided that the Plan has to pre-approve catheter, transluminal angioplasty, drug-coated, non-
laser coded C2623 provided on April 24, 2020.  
 
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 the Contour Next blood glucose test for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medically necessary reason to use this brand. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that the enrollee has a vision problem or blindness that requires the use of special 
glucometer test strip. There is no evidence that the enrollee is currently on an insulin pump or insulin delivery 
device that a requires specific glucometer or test strip. There is no medically necessary justification for why the 
enrollee needs this specific brand. 
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the Contour Next blood glucose test for the enrollee.