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

 
We decided that the Plan has to pay for radiation services (77301 and 77300) provided on March 3, 2020, 
through March 20, 2020. 
 
You asked the Plan to pay for the radiation services. You say that you would like reconsideration because other 
charges on this claim were paid. The Plan denied your request. The Plan says that this claim was not submitted 
timely. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for services furnished on or after January 
1, 2010, must be filed no later than the close of the period ending 1 calendar year after the date of service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiation services have been met. Specifically, the record indicates that this claim was filed on 
June 10, 2020. This is within the 1 year filing time limit. Therefore, we decided that the Plan has to pay for 
radiation services (77301 and 77300) provided on March 3, 2020, through March 20, 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 pay for wound  care  set,  for  negative  pressure  wound  therapy  
electrical  pump, includes all supplies and accessories (A6550) and disposable canister used with suction pump 
(A7000) provided November 22, 2019. 
 
You asked the Plan to pay for the wound care set and canister. You say that the claim was denied due to lack of 
explanation regarding excessive supplies during the enrollee's VAC therapy system. The attached documents 
validate the need for additional dressings and canisters. The Plan denied your request. The Plan says the 
records do not support the billed service. 
 
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  is not supported in the medical record. Specifically, this request exceeds the maximum 
number of units allowed per month as these services were previously paid and recouped by the same provider 
for the same date of service. Based on this information, we decided that Medicare rules for coverage of the 
wound care set and canister have not been met. Therefore, we decided that the Plan does not have to pay for 
wound  care  set,  for  negative  pressure  wound  therapy  electrical  pump, includes all supplies and 
accessories (A6550) and disposable canister used with suction pump (A7000) provided November 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided to the enrollee. 
 
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 these services required 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 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 subsequent nursing facility care provided to the 
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PureWick external catheter system. 
 
You asked the Plan to pre-approve the requested device. You say that you have two surgeries coming up and 
require catheters. The Plan denied your request. The Plan says the device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of a urological supply for the treatment of 
chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or 
retention is non-covered. 
 
We looked at the file and Medicare rules. The information provided does not indicate that you have a 
permanent urinary incontinence or permanent urinary retention. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a PureWick external catheter system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does nothave to pre-approve IRF admission and services.You asked the Plan to pre-approve IRF care. You say that based on the enrollee's medical history and poor wound healing, IPR level of care can provide wound care by a WOCN to prevent the risk of this wound becoming an infection that could become septic and cause a re-hospitalization. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to acute inpatient rehabilitation.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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to acute care for treated of pneumonia and a pleural effusion. He was discharged to skillednursing and requires care for a pressure ulcer.Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multipletherapies, 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 the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for hospital services provided on March 23, 2016, through March 25, 2016. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration because this 
claim was filed timely. The Plan denied your request. The Plan says that this claim was not filed timely. 
 
The Plan must follow Medicare rules. Medicare rules say that if failure to meet the deadline was caused by 
error or misrepresentation of an employee the time to file a claim will be extended through the last day of the 
sixth calendar month following the month in which either the beneficiary or the provider or supplier received 
notification that the error or misrepresentation was corrected. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital services have been met. Specifically, the record indicates that this claim was paid by 
Medicare and recouped on December 18, 2018. The claim was filed with the Plan on January 31, 2019 which is 
within the 6 month allowable time-frame. Therefore, we decided that the Plan has to pay for hospital services 
provided on March 23, 2016, through March 25, 2016.  
 
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 waive the deductible for lab services provided from January 6, 2020, 
to February 4, 2020. 
 
You asked the Plan to waive the deductible for lab services. You say that you disagree with the charges 
because you went to an in-network provider after surviving cancer and now lupus. 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. Your 
contract with the Plan says that there is a $150 deductible for outpatient diagnostic tests and therapeutic 
services and supplies.  
 
You received lab services from January 6, 2020, to February 4, 2020. The record shows that you had paid $0 
toward the $150 deductible prior to receiving the services. Therefore, you are responsible to pay the $150 
deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $150 deductible for outpatient diagnostic tests and therapeutic services 
and supplies. This cost sharing is a contractual obligation that had not been met at the time lab services were 
received on January 6, 2020 to February 4, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for lab services provided from January 6, 2020, to February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on December 26, 
2019. 
 
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges and 
are on a payment plan with the provider. 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. Your 
contract with the Plan says that there is a $185 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You had an office visit on December 26, 2019. The record shows that you had only paid $164.16 toward the 
$185 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$20.84.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $185 deductible for physician/practitioner services, including doctor's 
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was 
received on December 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible for 
an office visit provided on December 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on June 2, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford 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 a $225 
copayment for diagnostic radiology.  
 
You have been asked to pay the allowed amount of $161.21, which is less than the $225 copayment for a CT 
scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a CT scan provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay received. 
 
You asked the Plan to pay for the GeneSight Psychotropic Assay. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered 
benefit. 
 
The Plan follows Medicare rules. Medicare rules say that the GeneSight Psychotropic Assay is 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 pay for the GeneSight Psychotropic Assay. Our 
reviewer says that the documentation does not support that the services received were medically reasonable or 
necessary. Our physician reviewer found the documentation shows that you have a diagnosis of Adjustment 
Disorder with Mixed Anxiety and Depressed Mood a condition that does not meet the Medicare coverage 
criteria for the GeneSight Psychotropic Assay. You have not responded to at least one other medication which 
is noted in the record as well as being on multiple medications for your condition which increase the risk of 
adverse effects. You have been taking Ativan which has been effective. There is no documentation that you 
have tried an antidepressant medication as outlined by LCD L36325 specifies the testing to be ordered by a 
licensed psychiatrist or neuropsychiatrist. Therefore, you did not meet criteria for the services received. 
 
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 GeneSight Psychotropic Assay have not been met. Therefore, we decided 
that the Plan does not have to pay for the GeneSight Psychotropic Assay .
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from May 24, 2020, to June 2, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you 
should not be responsible for this cost share amount and you would like the Plan to reconsider your request. 
The Plan denied your request. The Plan says you received inpatient hospital care on the dates of service at issue 
in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $385 
copayment each day for days 1-5 for Inpatient hospital care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient 
hospital care from May 24, 2020, to June 2, 2020. You have been asked to pay a $385 copayment each day for 
days 1-5, totaling $1925. The inpatient hospital services fall 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 the inpatient hospital services provided from May 24, 2020, 
to June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 17, 
2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the long term electroencephalogram (EEG) (95720). 
 
You asked the Plan to pre-approve the long term EEG. You say that you recommend video EEG monitoring for 
differential diagnosis of ongoing spells and to determine the best treatment options. It is medically necessary 
for video EEG monitoring. The Plan denied your request. The Plan says the requested inpatient video EEG 
monitoring 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 the long term EEG. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found while a long term EEG monitoring study would be appropriate in this context, it 
cannot be said that provision of services in the inpatient setting at this time would reflect the most appropriate 
setting and level of care needed for this service at this time. Rather, the same type of evaluation could be 
conducted on an ambulatory basis (with video) on an ambulatory basis. An ambulatory study at this interval 
would be one that meets, but does not exceed, the enrollee's medical need. The service in question would 
otherwise exceed in scope/resources that needed to evaluate the enrollee's condition at this time (as more 
efficient alternatives are otherwise available). In as much the requested service cannot be said to be medically 
necessary at this time. 
 
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 long term EEG have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the long term electroencephalogram (EEG) (95720).
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 the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are 
no required medical services identified that are available at the LTACH, that are not available at the current 
health care setting being offered by the health plan. Consequently, the requested LTACH services are not 
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 86334) provided on 
January 24, 2020. 
 
You asked the Plan to pay for CPT code 86334. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 86334 is 2. You billed 3 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of CPT code 86334 have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code 86334) 
provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height 
adjustments), with any type side rails, with mattress (CPT Code E0265). 
 
You asked the Plan to pre-approve the total electric bed. You say that the bed is necessary. The Plan denied 
your request. The Plan says this item is not covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The rules say that a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
Therefore, we decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and 
height adjustments), with any type side rails, with mattress (CPT Code E0265).