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

We decided that the Plan has to pay for Oncology (breast), mRNA, gene expression profiling by real-time RT-
PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence provided 
on April 15, 2020. 
 
You asked the Plan to pay for Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 
genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services 
rendered are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that Oncology (breast), mRNA, gene expression profiling 
by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as 
recurrence is covered for enrollees with estrogen-receptor positive, node-negative carcinoma of the breast. 
 
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 Oncology (breast), mRNA, gene expression 
profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as recurrence. Our reviewer says that the documentation does support that the requested services are 
medically reasonable and necessary. Our physician reviewer found the enrollee has invasive ER+, PR+ HER2- 
carcinoma of the right breast. A right breast lumpectomy with sentinel lymph node biopsy was performed on 
April 3, 2020. LCA A54480 states that Oncotype DX Breast was developed for patients with the following 
findings: estrogen-receptor positive, node-negative carcinoma of the breast, as this enrollee has. Therefore, the 
enrollee met criteria for the services rendered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 
21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence have been met. 
Therefore, we decided that the Plan has to pay for Oncology (breast), mRNA, gene expression profiling by 
real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as 
recurrence provided on April 15, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on February 3, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the out-of-network 
charges and were not informed of them. 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 50% 
coinsurance for out-of-network DME and related supplies.  
 
You received DME on February 3, 2020 from an out-of-network provider. Therefore, you are responsible to 
pay your share of the out-of-network cost-sharing charges. The total allowed amount is $51.01 and 50% of that 
is $25.51. 
 
You have been asked to pay the total coinsurance amount of $25.51 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 
February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames received from a non-preferred provider on December 
6, 2019. 
 
You asked the Plan to pay for the frames. You say that you would like reconsideration for reimbursement for 
this service. The Plan denied your request. The Plan says this provider is not a preferred provider with the 
Plan's vision network that provides your supplemental benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when eyewear is provided by a preferred provider.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames have not been met. Specifically, the record indicates that you received these frames from 
a provider who is not a preferred provider in the Plan's vision network. 
 
Therefore, we decided that the Plan does not have to pay for frames received from a non-preferred provider on 
December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary for 
you. The Plan denied your request. The Plan says that this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth number 22, 23, 24, 
and 27 and pontics (D6245) for teeth number 25 and 26. 
 
You asked the Plan to pre-approve these services. You say that the requested dental services are necessary. The 
Plan denied your request. The Plan says that the teeth have a poor prognosis due to the amount of bone loss. 
The Plan also says that fixed bridges are only covered to replace one missing anterior tooth and, in this case, 
there are two missing anterior teeth. 
 
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 these services 
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 these services. Our reviewer says that 
the requested dental services are not medically necessary. Our physician reviewer found that the request is for a 
six unit bridge from tooth #22 to #27, replacing teeth #25 and #26. The provided x-rays show significant bone 
loss on the proposed abutment #24 of over 50%, and about 45% bone loss on tooth #23. The six unit bridge 
would be compromised by the weaker #23 and #24 units and the appliance would not be considered reasonable 
and necessary given the lack of proper bone support. In general terms, each unit of a bridge should have at least 
50% bone support in order to be considered in a potential treatment modality. Given the inadequacy of some of 
the abutments in a six unit bridge, the bridge would not be considered reasonable or necessary. 
 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve retainer crowns (D6740) for teeth number 22, 23, 24, and 27 and pontics (D6245) for teeth 
number 25 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast prosthesis, mastectomy sleeve (CPT Code 
L8010) and gradient compression stocking/sleeve, not otherwise specified (CPT Code A6549). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not covered by the Plan or Medicare. 
 
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 items have not been met. According to the Medicare rules, the 
items are not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to pre-
approve breast prosthesis, mastectomy sleeve (CPT Code L8010) and gradient compression stocking/sleeve, 
not otherwise specified (CPT Code A6549).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member is not safe at home and needs daily 
physician management. The Plan denied your request. The Plan says that you can safely receive the services 
you need in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a hip fracture in July 
2020. He is living in his home receiving home health care. The enrollee's medical problems are stable. There 
are no identified problems that need inpatient medical management. There are no complex nursing or 
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports 
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation 
therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that the enrollee's 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
have intense and complex needs that make inpatient care safer and more practical than care at a lower level. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital with acute congestive heart failure. In this case, the 
complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. She does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation 
therapy program. She continues to have a need for skilled therapy with ongoing safety concerns and a potential 
for functional improvement. However, there is no indication that she would require 15 hours a week of rehab 
services, under the supervision of a physician with at least 3 visits weekly to regain or maintain her functional 
status.  She is ambulating up to 8 feet with contact guard assistance, and is near her prior level of function. 
Therefore, the requested IRF services are 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you are requesting 
additional trips for medical appointments. The Plan denied your request. The Plan says you exhausted your 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 37th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from November 5, 2020, 
forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is necessary. The Plan 
denied your request. The Plan says the stay is not necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided for the admission of this patient does not 
meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 5, 
2020 forward as this patient was not shown to be a danger to herself or others. The patient was not showing any 
auditory or visual hallucinations and was cooperative/compliant with treatment well-being at baseline function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care from November 5, 2020, forward.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a knee X-ray (73562) and clinic visit 
(G0463) on May 7, 2020. 
 
You asked the Plan to waive the copayment for a knee X-ray and clinic visit. You say that the Plan should have 
covered the facility fee. 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 $105 
copayment for basic radiological services performed at an outpatient hospital.  
 
You have been asked to pay a $77.23 copayment for a knee X-ray and clinic visit. A knee X-ray and clinic visit 
fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means 
that you have been asked to pay less than or equal to the full 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 knee X-ray (73562) and clinic visit (G0463) on May 
7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 transfer to a LTACH is not medically necessary at this time. The enrollee continues 
to require acute hospital level of care services and is receiving appropriate care at the current acute care facility. 
The review has determined that the enrollee does not require services at the LTACH that are not available at 
the acute care hospital where the enrollee 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. 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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for professional services for allergen 
immunotherapy (95117) provided on March 19, 2020. 
 
You asked the Plan to waive the copayment for the professional services. You say that you would like 
reconsideration because you do not agree with the copayment that was assessed. The Plan denied your request. 
The Plan says your copayment was processed 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 $20 
copayment for Specialist Services.  
 
You have been asked to pay a $10.36 copayment for the professional services. The professional services fall 
within the Specialist Services benefit category. The allowed amount for this service is less than your contracted 
copayment. This means that you have been asked to pay less than your contracted copayment amount based on 
your EOC 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 professional services 
for allergen immunotherapy (95117) provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic services provided from January 3, 2020, to 
January 30, 2020 by an out of network provider. 
 
You asked the Plan to pay for the therapeutic services. You say that the Plan should pay this claim. 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 record shows this was an 
elective admission. The Plan has network providers available who can provide the services at issue in this 
appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan 
to pay for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic services 
provided from January 3, 2020, to January 30, 2020 by an out of network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services (CPT 81407, CPT 81408) provided on May 22, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that the services 
were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan indicates that this was billed incorrectly according to the rules 
established in the NCCI Policy Manual. However, research shows that the rule cited by the Plan cannot be 
found in the NCCI Policy Manual. The Plan has not provided documentation to support its denial. Without 
supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to 
pay for the lab services (CPT 81407, CPT 81408) provided on May 22, 2020.  
 
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.