Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
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 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 facet joint injections are only covered for certain 
indications. 
 
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 documentation does not support that the requested services are medically reasonable or necessary. Our 
physician reviewer found the enrollee has chronic low back pain and right lower extremity radicular pain for 
the last 3 years. Medical records document the pain as being constant, shooting, and throbbing. The enrollee 
had 80% pain relief after bilateral L4, L5 medial branch facet nerve blocks. Medical 
records, document that the enrollee received excellent 80% relief from the back and 
hip pain symptoms for two days, and then slowly the pain returned. The documentation does not document that 
the enrollee has satisfied all of the LCD requirements. Therefore, the enrollee does not meet criteria for the 
requested 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided. 
 
You asked the Plan to pay for lab test. You say that the Place of Service code is correct, and this service was 
medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because this testing was performed while the enrollee was a hospital inpatient and therefore the Place 
of Service (POS) code billed on this claim is incorrect. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent laboratory bills for a test on a 
sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient, off-campus 
outpatient hospital, or on-campus outpatient hospital respectively.  
 
We looked at the file and Medicare rules. This testing was performed on a hospital inpatient; therefore, the 
Place of Service (POS) code 22 ? indicating an on-campus outpatient hospital setting ? is not appropriate for 
this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been 
met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the manual wheelchair and attachments 
provided. 
 
You asked the Plan to waive the coinsurance for these items. The Plan denied your request. The Plan says that 
you have a 20% coinsurance for Medicare-covered durable medical equipment and related supplies. 
 
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 durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for these items. These items fall within the durable medical 
equipment (DME) and related supplies 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 manual wheelchair and attachments provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says these services could have been given at the observation level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including 
earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided to the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lymphedema therapy. 
 
You asked the Plan to pre-approve lymphedema therapy. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
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 lymphedema therapy. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the history and physical examination did not appear to be tailored to this the 
specific enrollee. There are too many inconsistencies as it relates to a patient with an above-knee amputation. 
There is insufficient documentation that the enrollee has the degree of lymphedema (that is refractory to more 
conservative treatments) of a severity to warrant lymphedema 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 lymphedema therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lymphedema therapy.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service requires 
the use of code 81479. In addition, the appropriate DEX Z identifier should be entered adjacent to the code in 
the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is too weak to go home from hospital 
admission for pneumonia due to COVID-19. The Plan denied your request. The Plan says the enrollee does not 
meet Medicare criteria for IRF. The enrollee can be covered for transfer to a SNF. 
 
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 that you do not require the intensity of services provided at an IRF. Specifically, you 
are not shown to require fifteen hours per week of rehabilitative services and 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for oncology services provided. 
 
You asked the Plan to waive the coinsurance for oncology services. You say that you think you are being 
overcharged. The Plan denied your request. The Plan says the correct coinsurance 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 50% 
coinsurance for outpatient diagnostic tests/out-of-network/radiology services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for oncology services. Your maximum 
out-of-pocket was met as of September 30, 2019. Oncology services falls within the outpatient diagnostic 
tests/out-of-network/radiology services 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 oncology services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient visit (99214) 
provided, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient visit. You say that you were 
approved as an in-network provider and would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says you do not have a contract with the member's specific 
plan. Thus, prior authorization was not obtained by the facility or the provider; therefore, payment has been 
correctly denied. 
 
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 established patient office or other outpatient 
visit (99214) provided, by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spine surgery. 
 
You asked the Plan to pre-approve spine surgery. 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 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 spine surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has lower back pain. There are no recent imaging studies in past 6 months. More 
information is needed for the criteria of the spine surgery to be 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 spine surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spine surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient hospital facility visits provided. 
 
You asked the Plan to waive the copayments for outpatient hospital facility visits. You say that you thought 
that you would only owe a $10 copayment per each visit. The Plan denied your request. The Plan says the 
claims were processed correctly, and you are being charged the correct 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 $200 
copayment for each outpatient hospital facility visit. 
 
You had outpatient hospital facility visits, for a total of 4 visits. 
Therefore, you are responsible to pay the total allowed amount of $601.10, which is less than the total 
copayment amount.   
 
You have been asked to pay the total copayment amount of $601.10 for outpatient hospital facility visits. 
Outpatient hospital facility visits fall within the outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 
copayments for outpatient hospital facility visits provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
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 Medicare guidelines for this device have 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 the monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found phobia of needles and non-compliance are not indications for continuous glucose monitoring. 
 
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 continuous glucose monitor.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve single-photon emission computerized tomography (SPECT) 
imaging with radiopharmaceutical localization. 
 
You asked the Plan to pre-approve the requested SPECT imaging. You say that it is felt that this imaging is 
needed to determine the best treatment options. The Plan denied your request. The Plan says that the enrollee 
does not have findings which require this imaging for Parkinson's disease diagnosis. 
 
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 requested SPECT imaging. Our 
reviewer says that the requested imaging is considered medically reasonable and necessary in this case. Our 
physician reviewer found the treating provider has ordered this imaging to delineate between drug-induced 
Parkinson's symptoms and Parkinson's disease. Due to the potential impact of the outcome of this study in the 
overall management of this patient, this test is indicated. It has direct impact on potential therapy and quality of 
life. 
 
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 requested SPECT imaging have been met. Therefore, we decided that the 
Plan has to pre-approve single-photon emission computerized tomography (SPECT) imaging with 
radiopharmaceutical localization.  
 
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 coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 19, 2020. 
 
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 billed are not supported by the documentation. 
 
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 CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation did not support that Carbamazepine, Levetiracetam, Topiramate, 
Digoxin, Clozapine, and Haloperidol testing were performed with blood sampling. Blood specimen collection 
is by venipuncture, however, the lab requisition states a urine specimen was collected. Therefore, the billed 
services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 26, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for physician services. You say that your doctor treated the enrollee and should not 
be penalized for failure to obtain authorization. The Plan denied your request. The Plan says you did not 
request 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan 
does not have to pay for the medical services provided on May 26, 2020 by an out of network 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. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient acute care, and do not require transfer. 
 
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 physician 
reviewer found that you were admitted to the acute hospital with a cough and shortness of breath. You had 
bilateral infiltrates on chest x-ray. You received supplemental oxygen, IV Rocephin, and Remdesivir. You 
continue to require acute hospital level of care services, and are receiving appropriate care at the present acute 
care hospital. You do not require services at the LTACH that are not available at the acute care hospital where 
he is currently receiving care. There are no services available at the LTACH that you require that are not 
available at the health care setting being offered by the health plan. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be 
furnished safely and effectively only on an inpatient basis. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on December 16, 2019. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
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 20% 
coinsurance for DME and related supplies.  
 
You received DME on December 16, 2019. The allowed amount is $70.92 and 20% of that is $14.18.  
 
You have been asked to pay the total coinsurance amount of $14.18 for DME. DME falls within the DME and 
related supplies 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 DME provided on 
December 16, 2019.