Persius/hicric huggingface dataset:
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 these services are medically necessary. 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 pneumonia. Your 
medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex 
nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found 
that your 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81210, 81235, 81275, 81276, 81292, 81295, 
81298, 81301, 81317, 81401, 81404) provided March 23, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the correct CPT code was not billed. 
 
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 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, & 81404 is 
not supported in the medical record. Specifically, ocal Coverage Article: Billing and Coding: Genomic 
Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (A56867) and Medicare Local Coverage 
Article for Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors (A57858) require use 
of CPT code 81445 to report targeted genomic sequencing. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 
81404) provided March 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation 
 
You asked the Plan to pre-approve additional trips. You say that the enrollee needs additional transportation to 
continue treatment. The Plan denied your request. The Plan says additional trips above the benefit allowance is 
not covered. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 40 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Once the enrollee has used 40 one-way 
trips, he will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synergy Seating Frame for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says the approved wheelchair includes a captain's chair. 
 
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 item. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's approved power wheelchair includes a captain's chair seat and a separate seat is not 
medically necessary. There are no extenuating factors to have a non standard seat frame with the approved 
Group 3 power wheelchair with captain's chair seat. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Synergy Seating Frame for the enrollee.
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 September 29, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this 
copayment. You say that you were not given an option to use private transportation. 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 $250 
copayment for ambulance services/ground travel.  
 
You have been asked to pay $242.48 which is less than your copayment amount of $250 for an ambulance trip. 
An ambulance trip falls within the ambulance services/ground travel 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 September 
29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cast application rendered on September 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that follow-up visits during the postoperative period are 
included in the global surgical package. 
 
We looked at the file and Medicare rules. The file shows that the services were related to a major surgical 
procedure performed on August 24, 2020. Payment for these services is included in the global surgical package 
for this procedure. Therefore, we decided that the Plan does not have to pay for the cast application rendered on 
September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for vision care provided on October 9, 2019. 
 
You asked the Plan to waive the copayment for vision care. You say that you disagree with the charges because 
this was an annual eye exam and you should not owe a copayment. 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 $40 
copayment for each eye exam to diagnose and treat diseases and conditions of the eye for vision care.  
 
You have been asked to pay a $40 copayment for vision care. Vision care falls within the vision 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 vision care provided on October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 10, 
2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that the colonoscopy should be 
considered preventative, not diagnostic, and you disagree with the charges. The Plan denied your request. The 
Plan says the claims were processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
The medical records show that you received a diagnostic colonoscopy on September 10, 2020. Therefore, you 
are responsible to pay the $325 copayment.  
 
You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 10, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a glucose monitor (HCPCS K0553) provided to the enrollee 
on February 25, 2020. 
 
You asked the Plan to pay for the monitor. You say that the Plan denied your request. The Plan says two 
diagnosis codes were submitted that are mutually exclusive to each other. 
 
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 HCPCS code K0553 is "Supply allowance for therapeutic 
continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service." 
 
We asked our coding 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 monitor. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found the supplier 
reported two conflicting diagnosis codes; E10.65 Type 1 Diabetes Mellitus with hyperglycemia and E11.65 
Type 2 Diabetes Mellitus with hyperglycemia this results in incorrect coding. There is a more appropriate code 
to report if Combination Type 1 and Type 2 Diabetes Mellitus. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not 
have to pay for a glucose monitor (HCPCS K0553) provided to the enrollee on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on September 21, 
2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the 
hospital outpatient clinic visit. 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 a hospital outpatient clinic visit provided on 
September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services (00918) provided on April 26, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration because you 
received a bill from the provider and thought this had been taken care of. The Plan denied your request. The 
Plan says the provider submitted the claim for these services past the 12 month timely filing deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the anesthesia services was not filed until May 11, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed.  
 
Please note, this provider may not be allowed by regulation to bill you directly for these services. Since you are 
being billed, you may wish to contact the Atlanta CMS Regional office to report this. You can contact the CMS 
Atlanta Regional Office at, (404)562-7500. Therefore, we decided that the Plan does not have to pay for the 
anesthesia services (00918) provided on April 26, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET myocardial imaging exam. 
 
You asked the Plan to pre-approve a PET myocardial imaging exam. You say that the requested PET 
myocardial imaging exam is medically necessary. The Plan denied your request. The Plan says that the 
requested PET myocardial imaging exam is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a PET myocardial imaging exam. Our 
reviewer says that the requested PET myocardial imaging exam is medically necessary. Our physician reviewer 
found the enrollee is confined to a wheelchair and therefore his activity level cannot be accurately assessed. He 
has known peripheral vascular disease and diabetes. It has been 2 years since his prior cardiac catheterization 
which showed moderate CAD. He is maintained on beta blockers chronically. Since he has known vascular 
disease, and his activity level cannot be assessed (his back pain has confined him to a wheelchair at present) 
and he is to undergo intermediate risk cardiovascular risk surgery, some type of cardiovascular ischemia 
assessment is reasonable based on ACC guidelines. Either pharmacologic stress SPECT or PET imaging is 
reasonable in this situation to assess CV risk depending on expertise and availability. Either technology is 
reasonable and indicated based on AHA/ACC practice guidelines (PET has Class 2A indication). Therefore 
based on published guidelines and the CMS criteria requiring safety, efficacy, medically necessity, and 
"furnished in accordance with accepted standards of medical practice", the proposed PET scanning meets CMS 
rules for use in this clinical situation. 
 
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 PET myocardial imaging exam have been met. Therefore, we decided that the 
Plan has to pre-approve a PET myocardial imaging exam.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lidocaine/prilocaine cream. 
 
You asked the Plan to pre-approve the lidocaine/prilocaine cream. You say that this is necessary. The Plan 
denied your request. The Plan says this is not a drug that can be covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve lidocaine/prilocaine cream.  
 
Benefits for the lidocaine/prilocaine cream may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the TempusxT gene panel. 
 
You asked the Plan to pay for the TempusxT gene panel. You say that you would like reconsideration because 
this testing is medically necessary and a valuable tool when determining treatment for the member. The Plan 
denied your request. The Plan says this service 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 pay for the TempusxT gene panel. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found next generation sequencing prior to 1st line therapy in head and neck or skin cancers 
is not considered a standard of care. Treatment guidelines do not involve molecular profiling of tumors and use 
is not supported by the NCCN Guidelines. 
 
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 TempusxT gene panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the TempusxT gene panel.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 9, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the medical services. You say that you do not understand why you need 
authorization. The Plan denied your request. The Plan says you did not request prior authorization for the out of 
network non-emergent services. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the medical services provided on September 9, 2020 by an out of network 
provider.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip 
fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your 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.