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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 4, 2020. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you have never had to pay 
for blood work from an annual physical before.  The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 $15 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds.  
 
You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. The record shows that 
laboratory work is not included as a part of the annual physical exam. 
 
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 laboratory work provided on August 4, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request is considered experimental and investigational. 
 
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 the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is a 68 year old female who was noted to have an abnormal ultrasoundof her left breast 
leading to a left breast biopsy and pathology which showed invasive malignant tumor cells and was diagnosed 
with invasive ductal carcinoma, SBR grade III. Partial mastectomy with radiation or sentinel node biopsy was 
discussed with the patient. L-Dex testing was requested. This screening tool identifies lymphedema post-
surgery much sooner than symptoms present, making early intervention more likely which is more effective 
when it is treated early. As this enrollee will be undergoing surgery which will increase risk of lymphedema, 
this test will directly help improve the overall outcome of this enrollee's condition. Therefore, this request for 
L-Dex will be considered medically 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 services have been met. Therefore, we decided that the Plan has to pre-
approve bioimpedance spectroscopy for the enrollee.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre System. 
 
You asked the Plan to pre-approve the Freestyle Libre System. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requirements for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic continuous glucose monitors are 
covered when specific criteria have been met.  
 
We looked at the file and Medicare rules. The records show that you are being treated with Januvia and that 
you are not on insulin therapy. There is no evidence that you are insulin-treated with multiple (three or more) 
daily injections of insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based 
on this information, we decided that Medicare rules for coverage of the Freestyle Libre System have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 2, 2019 by a non-
network 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 a non-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 October 2, 2019 
by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Cologuard test. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says based on the information in the records, this screening was last received in January 
2019. 
 
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 per the results of the previous test, you are not at average risk of developing colorectal cancer, as the test 
was positive, and colonoscopy was recommended. The test has been received in the past three years. 
 
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 Cologuard test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has been treated by the provider for 
skin cancer. The Plan denied your request. The Plan says the enrollee can adequately be treated in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The records provided do not indicate the enrollee 
is currently being treated by the requested provider. We found no exception that would require the Plan to pre-
approve these services. Therefore, we decided that the Plan does not have to pre-approve dermatology services 
to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for computed tomography (CT) of abdomen 
and pelvis; with contrast material(s) (74177), CT of thorax; with contrast material(s) (71260), CT of soft tissue 
neck; with contrast material(s) (70491), and low osmolar contrast material (Q9967) provided January 29, 2020, 
through August 26, 2020. 
 
You asked the Plan to waive the coinsurance for the CT scans. You say that you want the plan to pay for these 
services. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for Outpatient diagnostic tests.  
 
You have been asked to pay a 20% coinsurance for the CT scans. The CT scans fall within the outpatient 
diagnostic tests 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 coinsurance for computed tomography 
(CT) of abdomen and pelvis; with contrast material(s) (74177), CT of thorax; with contrast material(s) (71260), 
CT of soft tissue neck; with contrast material(s) (70491), and low osmolar contrast material (Q9967) provided 
January 29, 2020, through August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor for the 
enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the medical necessity guidelines. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has not been using insulin multiple times (3 or more) a day and his the treatment does not 
require frequent adjustment on the basis of testing results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 17, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on August 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided to the 
enrollee on May 21, 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 Medicare denies coverage for all cardiovascular risk assessment testing/panels, except the basic 
lipid panel,for symptomatic patients with suspected or documented cardiovascular disease. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Corus CAD testing was ordered on 5/21/20. No typical symptoms suggestive of coronary artery disease 
were noted. The results of the Corus CAD testing are in the case file. There are no clinical records to review. It 
is not documented how the cardiovascular risk assessment panel testing would impact the management and 
outcomes of the enrollee in this case. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiovascular risk assessment testing provided to the enrollee on May 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical implant placements and bone graft. 
 
You asked the Plan to pre-approve the surgical implant placements and bone graft. You say that you need the 
services so the dentist can make a new bridge for your teeth that were knocked out. The Plan denied your 
request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the surgical implant 
placements and bone graft.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided on August 13, 2020. 
 
You asked the Plan to pay for infrared therapy. You say that this is supported in the medical records. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light 
and/or heat, including monochromatic infrared energy, is non-covered.  
 
We looked at the file and Medicare rules. Infrared therapy is non-covered. Therefore, we decided that the Plan 
does not have to pay for infrared therapy (97026) provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9328 
provided from March 17, 2020 to June 10, 2020. 
 
You asked the Plan to pay for CPT code S9328. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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. In this case, CPT code S9328 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services with CPT code S9328 provided from March 17, 2020 to June 10, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records did not a second diagnostic medial branch block. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee only had one set of diagnostic medial branch blocks, which produced 100% pain relief for 
two hours. Two separate sets of blocks are required that produce greater than 80% pain relief. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from May 4, 
2020, to May 7, 2020 and billed under codes 99291. 
 
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 the submitted medical records do not include a critical care evaluation and 
management note supporting 30-74 minutes of critical care by the billing provider; therefore, the service cannot 
be verified. It is noted that multiple attempts were made to contact the provider for additional information. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes as well as medical records to support the services 
billed. In this case, code 99291 is not supported by the records provided due to the Medicare time requirement 
for this service. Medicare rules for coverage of this service have not been met. Therefore, we decided that the 
Plan does not have to pay for physician services provided to the enrollee from May 4, 2020, to May 7, 2020 
and billed under codes 99291.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided from April 30, 2020, to 
May 13, 2020. 
 
You asked the Plan to pay for inpatient psychiatric care. You say that these services were medically necessary, 
and you are not sure what you need to do to validate payment. The Plan denied your request. The Plan says the 
denial of payment for this inpatient stay is correct, because inpatient psychiatric care beyond 190 days per 
lifetime is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a 190-day lifetime limit for inpatient 
psychiatric hospital care.  
 
We looked at the file and Medicare rules. You have previously received 200 days of covered inpatient 
psychiatric hospital care, which is more than the 190-day lifetime limit. Based on this information, we decided 
that Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric care provided from April 30, 2020, to May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor for the 
enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no clinical documentation supporting that the criteria has been met. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case there is not sufficient clinical documentation such as the enrollee performing frequent 
glucose testing (4 or more times a day), insulin treatment regimen that requires frequent adjustments on the 
basis of blood glucose monitor results. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because the diagnostic injections only provider 60% and 70% pain relief with very short duration of relief. 
 
The Plan follows Medicare rules. Medicare rules state that radiofrequency ablation may be covered after two 
diagnostic medial blocks each provide a minimum of 80% relief of primary pain or 50% improvement in the 
ability to perform previously painful movement and activities of daily living, consistent with the agent used. 
 
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 facet joint injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested procedure. Our physician reviewer found 
the enrollee has had previous diagnostic medial branch blocks and reported 60% pain relief from one injection 
series and 70% relief from the other injection series. The duration of pain relief was very short. The request is 
for radiofrequency ablation of the facet joint. The medial branch blocks did not provide a positive response of 
at least 80% relief of primary pain (with duration of relief consistent with the agent used) or at least 50% 
improvement in the ability to perform previously painful movements and activities of daily living. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 97014) provided 
to you on September 14, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (CPT 99202, CPT 97014) provided to you on 
September 14, 2020.