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

 
We decided that the Plan does not have to pay for the GeneSight assay provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says supporting documentation is required for this to be considered for payment. 
 
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 pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical documentation supporting that the enrollee in this case is suffering with 
refractory moderate to severe depression (based upon DSM-V criteria) after at least one prior neuropsychiatric 
medication failure. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight assay provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient hospital care. You say that the requested inpatient hospital care is 
medically necessary. The Plan denied your request. The Plan says that the requested inpatient hospital care is 
not medically necessary. 
 
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. Specifically, it is the plan's responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's 
failure to obtain records that are within the plan?s control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for the inpatient hospital admission. A request for 
medical records was sent multiple times to the Plan with only a Utilization Review document as a response. 
Therefore, we decided that the Plan has to pre-approve inpatient hospital care.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77061) provided. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77061 
has a status code of I which is not valid for Medicare purposes. 
 
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 code 77061 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 77061 has a status code of I. This means that CPT code 77061 is not valid for Medicare purposes. Based 
on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis 
have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast 
tomosynthesis (77061) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and an 
attendant control (E2331). 
 
You asked the Plan to pre-approve an expandable controller and an attendant control. You say that this is 
necessary. 
 The Plan denied your request. The Plan says the enrollee can control all components through the provided 
switches. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary for one of the above functions. If an attendant control is provided in addition to a beneficiary-
operated drive control system, it will be denied as non-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 an expandable controller and an 
attendant control. Our reviewer says that the criteria for coverage of the requested items have not been met. 
Our physician reviewer found the documentation does not reveal that the patient requires other types of 
proportional input devices or non-proportional input devices. The patient does not need to operate 3 or more 
powered seating actuators through the drive control, a separate display, other electronic devices, or an attendant 
control. The patient's upper extremity strength and function are sufficient for the patient to control any power 
options through their own individual switches. The attendant control is requested in addition to a beneficiary-
operated drive control system. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller and an attendant control have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311) and an 
attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, expandable controller harness 
and electronic connection. 
 
You asked the Plan to pre-approve these items. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is not a medical need to control power options through the joystick. 
 
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 these items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. The 
documentation does not reveal that you require other types of proportional input devices or non-proportional 
input devices. You do not need to operate 3 or more powered seating actuators through the drive control, a 
separate display, other electronic or an attendant control. Your upper extremity strength and function are 
sufficient for you to control any power options through their own individual switches. Our physician reviewer 
found that your condition does not meet criteria for an expandable controller, expandable controller harness 
and electronic connection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an expandable controller, expandable controller harness and electronic connection.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on August 4, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you almost died from blood 
loss. You say that you do not feel like you should have to pay this copayment. 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 $200 
copayment for ambulance services/one-way trip.  
 
You have been asked to pay a $200 copayment for an ambulance trip. Since an ambulance trip was provided, 
the correct copayment has been applied. An ambulance trip falls within the ambulance services/one-way trip 
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 ambulance trip provided by a 
participating provider on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment (CMT); extraspinal, 1 or 
more regions (CPT Code 98943), application of a modality to 1 or more areas; traction, mechanical (CPT Code 
97012), office or other outpatient visit for the evaluation and management of an established patient (CPT Code 
99213-25) and electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, 
as part of a therapy plan of care (CPT Code G0283) provided on January 27, 2020. 
 
 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says routine chiropractic care is only covered for manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The member's EOC states 
that routine chiropractic care is only covered for manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for CPT Code 98943, CPT Code 97012, CPT Code 99213-25 and CPT Code 
G0283 provided on January 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services (S9501) provided December 4, 2019 to December 10, 2019.You asked the Plan to pay forthe home infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says the CPT code billed is not payable by Medicare.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 code S9501 is not supported in the medical record. Specifically CPT code S9501 has a status code of "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion services (S9501) provided December 4, 2019 to December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
charges because you were not charged in the past. 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 $225 
copayment for days 1-7 for inpatient hospital care.  
 
You had an inpatient hospital stay . The record shows that you had 
already paid $675 toward the inpatient hospital care benefit period. Therefore, you are responsible to pay 
remaining balance of $900, which is less than the total copayment amount for the stay.  
 
You have been asked to pay $900 for inpatient hospital care. Inpatient hospital care falls within the inpatient 
hospital 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 inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you should not have been 
discharged after the first visit. You state you should not be responsible for the copays because they should have 
kept you the first visit. The Plan denied your request. The Plan says the claims were processed accordingly 
with your 2019 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 file show that you received three (3) ambulance trips. 
You are asked to pay a $125 copayment per trip. Your total cost share responsibility is $375 ($125 copay X 3 
trips = $375). Your EOC states, enrollees must pay a $125 copayment per one-way trip for emergency 
ambulance services and non-emergency ambulance services. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for ambulance services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara multi-function respiratory assistance device, 
including ventilation, supplemental oxygen, nebulizer functionality, and a high-frequency chest wall oscillation 
(HFCWOD) function. 
 
You asked the Plan to pre-approve the Volara system including HFCWOD. You say that the Volara system is 
more than just an HFCWOD and should be considered for coverage as it would help with more issues that the 
enrollee has. The Plan denied your request. The Plan says this device does not have a code assigned for 
reimbursement. In addition, the HFCWOD function of this device is not considered necessary as the enrollee 
does not meet the Medicare criteria for this. The other functions of the system are already provided to the 
enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. The rules also 
 
 
say that items which serve the same purpose as an item already provided to the enrollee are not covered.  
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. The other functions of this device are for the same 
purpose as equipment that the enrollee already uses and has possession of. Without the HFCWOD function, the 
requested device is considered duplicative and not covered by Medicare. Therefore, we decided that the Plan 
does not have to pre-approve the Volara multi-function respiratory assistance device, including ventilation, 
supplemental oxygen, nebulizer functionality, and a high-frequency chest wall oscillation (HFCWOD) 
function.
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 SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had 
stable vital signs. You were treated for COVID-19 infection. You are acutely ill and intubated and not 
medically stable for SNF stay. The documentation does not support that you require the specialized skills, 
knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment. The documentation does not support that skilled nursing or 
skilled therapy services are required on a daily basis.  
 
 
 
As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF 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 SNF admission 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs 
which would meet the guidelines for SNF services on a daily basis. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 70544) provided on June 1, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 70544 is part 
of an edit pair with procedure code 70551. Procedure code 70551 is a column one code, and procedure code 
70544 is a column two code. Procedure code 70551 has been billed on this date of service, which means that 
procedure code 70544 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 70544) provided on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your 
condition has improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from November 6, 2020, forward. 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 continued services. Our physician reviewer found that active treatment was not taking place. The 
services were not reasonably expected or medically necessary to improve your condition, or for the purpose of 
diagnosis. The services were supervised and evaluated by a physician. Based upon review the records, you can 
be treated in a lesser restrictive setting. You are not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations, and were being cooperative and compliant without any acute threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible 
protective outer surface covering system. 
 
You asked the Plan to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface 
covering system. You say that you would like the plan to reconsider their denial. The Plan denied your request. 
The Plan says the requested item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that additions 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 addition, endoskeletal system, below 
knee, flexible protective outer surface covering system. Our reviewer says that the documentation does not 
support that the requested item is medically reasonable or necessary. Our physician reviewer found you 
underwent a right lower extremity amputation in 2010. The requested protective outer surface covering system, 
L5962, is a specialized cover intended to be worn over an existing prosthesis. It is to be used by an enrollee 
who has special needs for protection against unusually harsh environmental situations where it is necessary to 
protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and 
L5707. It is not documented that you have special needs for protection against unusually harsh environmental 
situations. Therefore, you do not meet criteria for the requested item. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of addition, endoskeletal system, below knee, flexible protective outer surface 
covering system have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, 
endoskeletal system, below knee, flexible protective outer surface covering system.