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

 
We decided that the Plan does not have to pay for a subsequent PET scan provided to the enrollee on April 20, 
2020. 
 
You asked the Plan to pay for the scan. You say that this is medically necessary. The Plan denied your request. 
The Plan says there are certain diagnosis codes that should be billed for these services. 
 
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 pay for the scan. Our reviewer says that the scan at 
issue in this case is not medically reasonable or necessary. Our physician reviewer found CMS guidelines for 
PET imaging specify a malignant diagnosis is necessary in order to allow for PET/CT to be approved for 
reimbursement. As such, a diagnosis of "enlarged lymph nodes" without a pathologic diagnosis of malignancy 
does not fulfill CMS guidelines for PET/CT imaging. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pay for a subsequent PET scan provided to the enrollee on April 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit (99285) on
May 5, 2020.
You asked the Plan to waive the copayment for an emergency department visit. You say that this copayment
represents an undue financial burden for you. The Plan denied your request. The Plan says 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 a $110
copayment for each Medicare-covered emergency room visit.
You have been asked to pay a $110 copayment for an emergency department visit. An 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
an emergency department visit (99285) on May 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lung removal (32484) and a trunk flap (15734) provided on 
March 12, 2020. 
 
You asked the Plan to pay for a lung removal and a trunk flap. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these codes are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our 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 a lung removal and a trunk flap. Our 
reviewer says that these codes are not supported. Our physician reviewer found the operative report did not 
include detailed documentation of a removal of lung, other than pneumonectomy; single segment 
(segmentectomy) or a muscle, myocutaneous, or fasciocutaneous flap; trunk. Therefore, these codes cannot be 
verified. 
 
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 lung removal and a trunk flap have not been met. Therefore, we decided that 
the Plan does not have to pay for a lung removal (32484) and a trunk flap (15734) provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on January 29, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not know why you are being 
billed for this. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient diagnostic tests/advanced imaging services.  
 
You have been asked to pay a $225 copayment for a CT scan. Since a CT scan was provided, the correct 
copayment has been applied. A CT scan falls within the outpatient diagnostic tests/advanced imaging 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 copayment for a CT scan provided by a 
participating provider on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office services provided on 
March 12, 2020. 
 
You asked the Plan to waive the copayment for the specialist office services. You say that you went to a 
primary care physician (PCP) visit with this provider who is dual specialist for cardiology and was charged for 
the specialist copayment rather than the PCP copayment. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC 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).  
 
Review of the medical records show that you received cardiology specialist services on March 12, 2020. You 
were asked to pay a $20 copayment for the specialist office visit. Your EOC states that enrollees must pay a 
$20 copayment for the specialist office visit. 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 
specialist office services provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient specialist office visit provided June 18, 2020.
You asked the Plan to waive the copayment for the office visit. You say that your first visit to this doctor, all of your concerns were not address. You informed them and they made a second visit. You do not feel obligated to pay for the second visit. The Plan denied your request. The Plan says the claim has been 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 $35 copayment for each specialist visit. You have been asked to pay $35 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits 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 outpatient specialist office visit provided June 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a benign lesion (11406) provided on January 30, 2020.
You asked the Plan to pay for the excision of a benign lesion. You say that this is documented. The Plan denied your request. The Plan says the records do not include the size of the excised tumor.
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 11406 is excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm. 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 excision of a benign lesion. Our reviewer says that this code is not supported. Our physician reviewer found the provided documentation does not note a lesion diameter over 4.0 cm, therefore, this service cannot be verified. 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 excision of a benign lesion have not been met. Therefore, we decided that the Plan does not have to pay for the excision of a benign lesion (11406) provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 3, 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 Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 18, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing. The Plan denied your request. The
Plan says the denial of payment for this testing is correct, because the documentation submitted does not
include a valid physician order, lab requisition, or medical records stating exactly which tests were to be
performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab testing billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided by an out-of-network provider on
March 6, 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 the authorization is for a different 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 in this with the provider who ended up rendering them. 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
hospital services provided by an out-of-network provider on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with power tilt, 
power recline and power elevating leg rests. 
 
You asked the Plan to pre-approve a Group 3 PWC with power tilt, power recline and power elevating leg 
rests. You say that the requested items are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria is 
met. 
 
 
 
 
 
 
 
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 Group 3 PWC with power tilt, power 
recline and power elevating leg rests. Our reviewer says that the items are not medically necessary. Our 
physician reviewer found based on the medical records provided there is no documentation that you meet the 
coverage criteria for a group 3 power wheelchair with power tilt, power recline and power elevating leg rests. 
You do not have a medical diagnosis of neurological disease, myopathy or congenital skeletal deformity 
causing a mobility limitation for which a Group 3 power wheelchair base would be 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 Group 3 PWC with power tilt, power recline and power elevating leg rests 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power 
wheelchair (PWC) with power tilt, power recline and power elevating leg rests.
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 records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, 
longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit 
and/or participate in an IRF level of 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires LTACH care. The 
Plan denied your request. The Plan says the enrollee's needs are being met in the current setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 72-year-old female with a history of COPD on home O2, non-
ischemic cardiomyopathy, chronic atrial fibrillation, thoracic aneurysm of aorta repaired endovascularly who 
was admitted to acute care inpatient hospital on 8/14/20 for acute on chronic respiratory failure with hypoxia 
and hypercapnia. She was placed on BIPAP, antibiotics, and transferred to ICU.  
 
There is no documentation provided requiring admission to a LTACH. The enrollee is receiving appropriate 
care at the present acute care facility and when she is considered medically stable by the treating team will be 
an appropriate candidate for care at a less intense level such as a skilled nursing facility (SNF). The review has 
determined that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee 
requires that are not available at the health care setting being offered by the health plan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing panels and
individual assays for other analytes provided on January 9, 2020.
You asked the Plan to pay for the drug testing. You say that this testing should be covered. The Plan denied
your request. The Plan says there is no valid order that identifies the requested testing.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the
treating provider.
The file includes an order for a chronic care management profile but offers no specifics as to which drugs are
tested in that panel. As such, we cannot confirm the intent for the rendered testing to be performed. Therefore,
we decided that the Plan does not have to pay for the presumptive and definitive drug testing panels and
individual assays for other analytes provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that an inpatient bed-stay is medically necessary for the enrollee's scheduled arthroplasty. The Plan denied your request. The Plan says the enrollee has not meet the guidelines for coverage of an inpatient hospital stay.
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 inpatient hospital admission. Our reviewer says that an inpatient hospital is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is having routine total joint surgery. This surgery can be done safely with an observational or outpatient stay. There is no need for inpatient admission. 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alginate or other fiber gelling dressing (A6197).
You asked the Plan to pre-approve alginate or other fiber gelling dressing. You say that the requested items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). 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 alginate or other fiber gelling dressing. Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee has a wound and per description the wound is not indicated to have moderately to highly exudative drainage. The review has determined that the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of alginate or other fiber gelling dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve alginate or other fiber gelling dressing (A6197).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug assays for six substances provided on January 8,
2020 billed with codes 80157, 80159, 80162, 80173, 80177, and 80201
You asked the Plan to pay for the billed testing. You say that these tests should be covered. The Plan denied
your request. The Plan says there is no evidence these tests were performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The codes billed in this case are for testing done using plasma/serum. The record only shows that a urine
sample was received, no blood sample. As there is no blood sample in evidence, these codes are not supported.
Therefore, we decided that the Plan does not have to pay for the drug assays for six substances provided on
January 8, 2020 billed with codes 80157, 80159, 80162, 80173, 80177, and 80201