Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 21, 2020.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 psychotherapy services. We found no exception that wouldrequire the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services providedon February 21, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the urgent care service provided on April 
11, 2020 and the emergency department service provided on May 20, 2020 
 
You asked the Plan to waive the copayments for the urgent care service and the emergency department service. 
You say that physician offices were closed and you had no other option than to go to the urgent care facility 
and emergency room. The Plan denied your request. The Plan says you were charged the copayments correctly. 
 
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 $45 
copayment for Urgent care, a $90 copayment for Emergency care.  
 
You have been asked to pay a $45 copayment for the urgent care service, and a $90 copayment for emergency 
care. 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 copayments for the urgent care service provided on April 11, 2020 and 
the emergency department service provided on May 20, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 29, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. 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 the Guardant360 testing provided on March 29, 
2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET CT scan from the skull base to 
mid-thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found in this 
case since PET/CT has been done twice and has been used to assess treatment failure or success it is reasonable 
to assess the skull base with this technique to evaluate whether further antimicrobial therapy is necessary. The 
comparison of the same imaging modality is necessary in the best interests of the enrollee and since there have 
been 2 PET/CT scans so far a third PET/CT after completion of his antimicrobial therapy is 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 a PET CT scan from the skull base to mid-thigh have been met. Therefore, we 
decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan from the skull base to mid-thigh (78815).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 13, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services received are not a covered benefit when 
provided by an out of network provider. 
 
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 laboratory services provided on February 13, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical assistant services rendered on January 24, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the provider type is not payable.The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS.We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical assistant services rendered on January 24, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit (99282) 
provided April 20, 2020. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you should not 
have an emergency room copay because you developed complications after surgery because they wrapped the 
bandages incorrectly and you went to the same hospital you had the surgery. The Plan denied your request. The 
Plan says this claim was processed and the correct copayment was applied per the plan benefits. 
 
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 $120 
copay per visit for Medicare covered emergency care.  
 
You have been asked to pay $120 copay for the emergency department visit. The emergency department visit 
falls within the Emergency 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 emergency department visit (99282) provided April 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure (52356) 
provided May 6, 2020. 
 
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that you had surgery, 
removal of kidney stone in right kidney and it was not successful. You had the same surgery performed June 
10, 2020. The issue is why are you being billed twice for the same procedure. The Plan denied your request. 
The Plan says this claim was processed and the correct copayment 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 $225 
copayment for each Medicare covered ambulatory surgical center visit.  
 
You have been asked to pay $225 copayment for the cystourethroscopy procedure. The cystourethroscopy 
procedure falls within the outpatient surgery 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 cystourethroscopy procedure (52356) provided May 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CT thorax provided on April 27, 2020. 
 
You asked the Plan to waive the coinsurance for the CT thorax. You say that you cannot afford the 
coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly. 
 
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 other outpatient diagnostic tests.  
 
You have been asked to pay 20% coinsurance for the CT thorax. the CT thorax falls within the 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 coinsurance for the CT thorax provided on 
April 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF 
admission. 
 
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 pre-approve admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the 
hospital the enrollee had stabilized medically.  At the time of discharge, he did not require any skilled nursing 
or rehab services on a daily basis at an inpatient level of care.  He was not expected to make measurable gains 
within a reasonable and predictable period of time or require daily skilled therapy to prevent deterioration with 
mobility or activities of daily living.  The enrollee did not require skilled therapy to establish a safe and 
effective maintenance program.  As a practical matter, the enrollee did not require any skilled services on an 
inpatient basis, at a SNF level of care at the time of discharge from the hospital. 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your therapy needs can be met at a lower level of 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 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. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for 
skilled therapy with ongoing safety concerns and a potential for functional improvement, however, the 
documentation doesn?t support that you would meet criteria for admission to an acute inpatient rehabilitation 
facility. There is no indication that you would tolerate skilled rehabilitation in an IRF, participating in rehab 
services 15 hours a week. You do not require the supervision of a physician with at least 3 visits weekly to 
regain or maintain your medical status. You are unable to ambulate and the documentation supports that you 
are weak and would likely not be able to tolerate an intensive program. Your needs can be met at a lower level 
of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide this care. Therefore, coverage criteria has not been met. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex Interlaminar Stabilization device (22868, 
22867). 
 
You asked the Plan to pre-approve a Coflex Interlaminar Stabilization device. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not 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 a Coflex Interlaminar Stabilization 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the device is experimental. More research is needed to 
show safety and efficacy. Also there is no spinal instability demonstrated on imaging studies. The device is not 
needed. 
 
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 Coflex Interlaminar Stabilization device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Coflex Interlaminar Stabilization device (22868, 22867).
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 there is no documented evidence of medical issues that require monitoring by an 
inpatient rehab physician three times a week. The documentation does not support that there is a need for an 
intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care at the current 
functional status. The enrollee will not be able to make a significant functional recovery in a predicted period. 
This enrollee, does not meet the CMS coverage criteria for an IRF admission. The enrollee's rehab needs can be 
met in an alternate, less intense setting such as in a skilled nursing facility (SNF). 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready 
for discharge from the inpatient rehabilitation facility. You do not require skilled nursing and/or skilled therapy 
services on a daily basis. You are medically stable and can receive further rehab services at a lower level of 
care. Although further rehab services would be appropriate to improve function, as a practical matter, the daily 
skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any 
parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable 
without any acute exacerbations of chronic medical problems. Your physical function is at or near your 
baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 
services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve glaucoma drainage devices (iStent initial device and 
additional device for both eyes). 
 
You asked the Plan to pre-approve glaucoma drainage devices (iStent initial device and additional device for 
both eyes). You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additional device insertions are considered not 
medically reasonable and 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 glaucoma drainage devices (iStent 
initial device and additional device for both eyes). Our reviewer says that the documentation does not support 
that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee 
has a diagnosis of Age-related nuclear cataract, bilateral. The condemnation does not support that the enrollee 
has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of Insertion of 
glaucoma drainage devices (iStent initial device and additional device for both eyes). Additional stents, per 
LCD are non-covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of glaucoma drainage devices (iStent initial device and additional device for both 
eyes) have not been met. Therefore, we decided that the Plan does not have to pre-approve glaucoma drainage 
devices (iStent initial device and additional device for both eyes).