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

 
We decided that the Plan does not have to pre-approve the WATS 3D brush biopsy rendered on January 15, 
2020. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services were 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 these services. Our reviewer says that 
the services were not medically necessary. Our physician reviewer found the submitted records do not support 
high likelihood of Barrett's esophagus dysplasia for this enrollee. She has a known history of short segment 
Barrett's, for which WATS 3D confirmation was not needed. The WATS 3D brush biopsy was not reasonable 
or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the WATS 3D brush biopsy rendered on January 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient observation services 
provided on November 1, 2019, through November 2, 2019. 
 
You asked the Plan to waive the copayment for the outpatient observation services. You say that you disagree 
with the copayment as charged. The Plan denied your request. The Plan says the copayment processed 
correctly for this case. 
 
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 $400 
copayment for outpatient observation care.  
 
You have been asked to pay a $400 copayment for the outpatient observation services. The services provided 
fall within the outpatient observation 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 outpatient observation services provided on November 1, 2019, through November 2, 2019.  
 
Your complaint about how the hospital coded the services you received is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81162, 81163). 
 
You asked the Plan to pre-approve the genetic testing. You say that the service is medically necessary. The 
Plan denied your request. The Plan says there is no personal history of cancer, and therefore this test is 
considered a screening test and is not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing at issue in this appeal is being requested solely for screening purposes. Medicare does not cover this 
test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve genetic 
testing (81162, 81163).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete blood count services coded 85025 provided on 
June 29, 2020. 
 
You asked the Plan to pay for the complete blood count services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85025 is Blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the documentation submitted 
did not include laboratory results of a complete blood count. Based on this information, we decided that 
Medicare rules for coverage of the complete blood count services have not been met. Therefore, we decided 
that the Plan does not have to pay for the complete blood count services coded 85025 provided on June 29, 
2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the abdomen (74183). 
 
You asked the Plan to pre-approve a MRI of the abdomen. You say that the service is medically necessary. The 
Plan denied your request. The Plan says that the clinical information provided does not describe a change in the 
size of the lesion and, therefore, the request is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MRI of the abdomen. Our reviewer 
says that the service is medically necessary. Our physician reviewer found the medical records show that a 
dedicated study was indicated and the MRI was recommended at the time of the last computerized tomography 
(CT) scan. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MRI abdomen have been met. Specifically, the records indicated that a MRI is 
medically necessary and reasonable. Therefore, we decided that the Plan has to pre-approve a magnetic 
resonance imaging (MRI) of the abdomen (74183).  
 
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 pre-approve a CardioMEMS implant (C2624). 
 
You asked the Plan to pre-approve a CardioMEMS implant. You say that this is medically necessary and 
indicated. The Plan denied your request. The Plan says this is investigational. 
 
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 a CardioMEMS implant. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a CardioMEMs device has been demonstrated to help reduce hospital readmission 
compared to standard medical therapy in only one randomized prospective trial. Moreover, concerns have been 
raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the 
CardioMEMS device is uncertain at this time according to leading authorities and it is not recommended in 
current guidelines for the treatment of heart 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 a CardioMEMS implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS implant (C2624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies for self-administered medications received from 
June 19, 2020 to June 28, 2020. 
 
You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. 
The Plan says the charges should be submitted to the prescription drug plan. 
 
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 pay for supplies for self-administered 
medications received from June 19, 2020 to June 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 office visit provided on May 7, 2020 by an out 
of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit services coded 99285 
provided on May 18, 2020. 
 
You asked the Plan to pay for the emergency department visit services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature 
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high 
severity and pose an immediate significant threat to life or physiologic function. 
 
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 emergency department visit services. 
Our reviewer says that the services billed are not supported by the documentation. Our physician reviewer 
found the documentation does not meet criteria for the use of code 99285. Emergency room report supports A 
comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity 
for Undiagnosed new problem with uncertain prognosis. Therefore, CPT 99284 would be the appropriate code 
to report in this case. 
 
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 emergency department visit services have not been met. Therefore, we 
decided that the Plan does not have to pay for the emergency department visit services coded 99285 provided 
on May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prosthetic leg with advanced foot and ankle features. 
 
You asked the Plan to pre-approve the K3 prosthesis. You say that you are requesting the plan to review this 
appeal and all attached documentation regarding the L5986 and L5987 codes for authorization. The Plan 
denied your request. The Plan says this request exceeds the enrollee's need. 
 
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 K3 prosthesis. 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 physician note documenting an evaluation or examination supporting his 
K3 ambulatory status. Therefore, the documentation does not support the requirements of the LCD and 
coverage is not recommended. 
 
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 K3 prosthesis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the prosthetic leg with advanced foot and ankle features.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the abdominal ultrasound (93978). 
 
You asked the Plan to pre-approve the abdominal ultrasound. You say that the records provided should support 
the necessity of the service in dispute. The Plan denied your request. The Plan says that the request does not 
meet the criteria for abdominal ultrasound as the records shows the aneurysm was 3.5 cm on the ultrasound 
done in November 2019. 
 
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 the abdominal ultrasound. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a small/moderate abdominal aortic aneurysm first diagnosed 1 year 
ago. He has multiple risk factors for expansion including known CAD and hypertension. Although there are 
some guideline recommendations for 2-3 year repeat ultrasound of aortic aneurysms of this size, as noted in the 
guidelines, these recommendations are based on weak data and additional risk factors for expansion should be 
considered when deciding on appropriate follow-up intervals (1). Given that this aortic aneurysm was only first 
diagnosed last year and the enrollee has additional risk factors for expansion and rupture, a repeat ultrasound at 
one year is medically reasonable to access the stability of the aneurysm. If unchanged, longer intervals of 
ultrasound follow-up could then be considered going forward. The repeat ultrasound at one year does meet the 
CMS NCD for ultrasound procedures requirement for medical necessity and frequency based on the published 
data. 
 
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 abdominal ultrasound have been met. Therefore, we decided that the Plan 
has to pre-approve the abdominal ultrasound (93978).  
 
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 preapprove power wheelchair components defined by codes E2311, 
E2377, E2313, and K0108. 
 
You asked the Plan to preapprove the power wheelchair components.. You say that the power three wheelchair 
and all components are necessary for the enrollee. The Plan denied your request.  
The Plan says the Group 3 Power wheelchair is necessary, but the expandable controller (E2377), expandable 
harness (E2313) and electronics (E2311) and elbow pads (K0108) are not. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation. The rules say K0108 is not a code that is used at time of initial issue.  
 
Documentation shows that the member's wrist strength is 4+/5 with good grip strength. This upper limb 
strength and function are adequate for the member to be able to control the power options using their own 
switches which are included in the allowance of these power options. Although there are three approved power 
options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these 
power options through the joystick. Therefore, we decided that the Plan does not have to preapprove power 
wheelchair components defined by codes E2311, E2377, E2313, and K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care provided on August 15, 2019. 
 
You asked the Plan to pay for the initial hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not received within the 365 day timely filing period. 
 
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 initial hospital care was not filed until September 18, 2020. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the initial hospital care provided on August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal protective equipment and first intraoral 
periapical x-ray provided on September 3, 2020. 
 
You asked the Plan to pay for the personal protective equipment and first intraoral periapical x-ray. You say 
that you already paid 50% at the time of the service. You also say that these services should be covered because 
this provider was given to you by the Plan. The Plan denied your request. The Plan says the personal protective 
equipment is not a covered service. The Plan also says that x-ray benefit had been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, personal protective equipment is not 
among those covered under this benefit. The contract also clearly states that dental x-ray(s) are limited to one 
per year. The record shows that you received a first intraoral periapical x-ray on July 15, 2020, and your x-ray 
benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the personal 
protective equipment and first intraoral periapical x-ray provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on 
December 2, 2019. 
 
You asked the Plan to waive the copayment for a spinal canal injection. You say that the charges are fraudulent 
because you did not receive any services. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
The medical records show that you received a spinal canal injection on December 2, 2019. Therefore, you are 
responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for a spinal canal injection. A spinal canal injection 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 spinal canal injection provided 
on December 2, 2019.
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 required stand-by assistance to contact guard assistance with functional mobility 
including walking to seventy-five feet with a rolling walker. 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).