Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 occupational therapy visits. 
 
You asked the Plan to pre-approve 24 occupational therapy visits. The Plan denied your request. The Plan says 
the enrollee has already had the amount of therapy allowed under the plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 24 occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the unique skills of a professional therapist are 
not required to safely and effectively provide treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 24 occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 24 occupational therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Lumbar Spine 
(72131). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 CT scan. Our reviewer says that a 
CT scan is not medically necessary. Our physician reviewer found there was no documentation of a fall or 
injury suggestive of a body change, x-ray didn't reveal fracture or findings which might warrant surgery, 
physical findings were normal, and there was no report of having failed weight loss and formal physical 
therapy. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the Lumbar Spine (72131).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L2999). 
 
You asked the Plan to pay for the orthosis. You say that the enrollee requires the device for arthritis. The Plan 
denied your request. The Plan says this is not a covered indication. 
 
The Plan must follow Medicare rules. Medicare rules say that knee joint extensions coded by (L2999) are 
covered for beneficiaries who require knee extension assist in the absence of any co-existing joint contracture. 
The enrollee does not meet coverage criteria. Therefore, we decided that the Plan does not have to pay for a 
knee orthosis (L2999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for wrist hand orthosis (L3916) and shoulder elbow wrist hand 
orthosis (L3960) provided to the enrollee on March 12, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. 
Healthcare Common Procedure Coding System (HCPCS) code L3960 LT (1 Unit) remains not supported. The 
medical records submitted do not include sufficient detail to support the supply as billed. The documentation 
submitted did not include a Delivery Ticket for the specific reported supply for the billed date of service. The 
billed date of service for the supply is noted as March 12, 2020 and the delivery date of the billed supply is 
documented as April 27, 2020; therefore, the billed supply code cannot be supported. It is noted that multiple 
attempts were made to contact the provider for additional information. 
 
Healthcare Common Procedure Coding System (HCPCS) code L3960 LT (1 Unit) remains not supported. The 
medical records submitted do not include sufficient detail to support the supply as billed. The documentation 
submitted did not include a Delivery Ticket for the specific reported supply for the billed date of service. The 
billed date of service for the supply is noted as March 12, 2020 and the delivery date of the billed supply is 
documented as April 27, 2020; therefore, the billed supply code cannot be supported. It is noted that multiple 
attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding 
System (HCPCS) code L3916 RT (1 Unit) remains not supported. The medical records submitted do not 
include sufficient detail to support the supply as billed. The documentation submitted did not include a 
Delivery Ticket for the specific reported supply for the billed date of service. The billed date of service for the 
supply is noted as March 12, 2020 and the delivery date of the billed supply is documented as April 27, 2020; 
therefore, the billed supply code cannot be supported. It is noted that multiple attempts were made to contact 
the provider for additional information. Therefore, we decided that the Plan does not have to pay for wrist hand 
orthosis (L3916) and shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on March 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures (97112) and therapeutic activities 
(97350) provided from January 14, 2020 to January 22, 2020. 
 
You asked the Plan to pay for therapeutic procedures and therapeutic activities. You say that these services 
were medically necessary. The Plan denied your request. The Plan says these codes are not supported in the 
records. 
 
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 97112 is therapeutic procedure, 1 or more areas, each 15 
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities and 97350 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97112 and 97350 are not supported in the medical record. Specifically, these are time 
based codes. The records do not document the time spent on these services. Based on this information, we 
decided that Medicare rules for coverage of therapeutic procedures and therapeutic activities have not been 
met. Therefore, we decided that the Plan does not have to pay for therapeutic procedures (97112) and 
therapeutic activities (97350) provided from January 14, 2020 to January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial perfusion imaging, tomographic (SPECT) (CPT 
Code 78452) on August 27, 2019. 
 
You asked the Plan to pay for the imaging. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the imaging have not been met. Review of the file show that the 
indications on the stress test document do not match the history per your clinical cardiologist, although they do 
state the study was for "cardiovascular screening" and for "safety of exercise" which you were already doing 
and were encouraged to continue by the provider. The rules say that myocardial perfusion studies performed 
based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical 
examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be 
considered screening and denied as not covered by Medicare. Therefore, we decided that the Plan does not 
have to pay for myocardial perfusion imaging, tomographic (SPECT) (CPT Code 78452) on August 27, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ultrasounds provided by a participating 
provider on February 5, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you should only be charged $110. 
You say that the ultrasounds were performed on the same day. The Plan denied your request. The Plan says the 
correct copayments have 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 $110 
copayment for outpatient diagnostic tests/other outpatient diagnostic tests.  
 
You have been asked to pay a $110 copayment for each ultrasound. The total amount you are being asked to 
pay is $220 ($110 x 2 ultrasounds = $110). Since two separate ultrasounds were provided, the correct 
copayments have been applied.an ultrasound falls within the outpatient diagnostic tests/other 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 copayment for two ultrasounds provided 
by a participating provider on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids purchased on November 4, 2019 from an 
out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you have been told the hearing aids from the 
network supplemental hearing vendor were not very good and you do not see why the Plan cannot pay one 
place as good as another. The Plan denied your request. The Plan says 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. 
 
Review of the file show that you purchased the hearing aids on November 4, 2019 from an out-of-network 
provider. Your EOC says that you may choose to order hearing aids through your two (2) network 
supplemental hearing vendors. 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 hearing aids purchased on 
November 4, 2019 from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 7, 2020 to 
April 5, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 7, 2020 to April 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CYP panel rendered on July 3, 2019. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are 
non-covered. 
 
We looked at the file and Medicare rules. The services at issue are a CYP panel. The services were billed with 
code 81479 and are not covered. Therefore, we decided that the Plan does not have to pay for the CYP panel 
rendered on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight testing provided on October 24, 2019. 
 
You asked the Plan to pay for the testing services. You say that the use of the testing helps eliminate ineffective 
therapy. The Plan denied your request. The Plan says the service is considered investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that testing may be ordered for those who are 
suffering with refractory moderate to severe depression after at least one prior neuropsychiatric medication 
failure.   
 
We looked at the file and Medicare rules. In this case, there were insufficient records provided to show the 
enrollee has been suffering from depression after medication failure. Based on this information, we decided 
that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the GeneSight testing provided on October 24, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from March 16, 2020 to 
April 12, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from March 16, 2020 to April 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided 
on March 8, 2019. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the 
documentation does not include a lab order including the itemized list of drugs. 
 
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 testing at issue is not supported in the medical record. There is no evidence that shows the test 
was individualized to identify specific non-prescribed medications or illicit substances. The records provided 
do not document concerns based on clinical review and judgement. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the presumptive and definitive drug testing services provided on March 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the intravenous chemotherapy 
administration (96413) and the Nivolumab injection (J9299) provided on February 5, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance 
has been applied correctly to the services provided. 
 
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% 
coinsurance for Medicare Part B covered drugs and Chemotherapy Drugs provided at an in-network specialist?s 
office or outpatient hospital.  
 
You have been asked to pay $2,763.41($13,817.07 allowed amount x 20% coinsurance) for the Chemotherapy 
infusion and Medicare Part B covered injection provided at an in-network outpatient hospital. 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 the intravenous chemotherapy administration (96413) and the 
Nivolumab injection (J9299) provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #13. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the obturation is not 
properly condensed nor filled sufficiently close to the radiographic apex, and there is periapical pathology 
noted at the apex of tooth #13. The Plan also says that placing a crown on tooth #13 in its current state is not 
recommended, and does not meet the coverage criteria. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
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 crown. Our reviewer says that the 
crown is not medically necessary. Our physician reviewer found the criteria for coverage for a crown (D2750) 
for tooth #13 does not meet the criteria for coverage at this time due to the inadequate root canal and possible 
periapical infection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2750) for tooth #13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 7, 2019. 
 
You asked the Plan to pay for the services provided. You say that you were assured the provider was in 
network when they are not. The Plan denied your request. The Plan says the cost share was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.  
 
The documentation shows that you received services from an out-of-network provider. The services you asked 
the Plan to pay for falls within the physician services and outpatient diagnostic tests benefit categories. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This cost 
sharing is a contractual obligation that had not been met at the time the services were received. Therefore, we 
decided that the Plan does not have to pay for the medical services provided on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) and a lumbar-sacral orthosis 
(L0650) provided to the enrollee on March 17, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a 
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary 
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for a wrist-
hand orthosis (L3916) and a lumbar-sacral orthosis (L0650) provided to the enrollee on March 17, 2020.