Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90837) provided on August 5, 2020 to 
August 19, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy. You say that these services are medically necessary and 
should be covered by the Plan. The Plan denied your request. The Plan says prior authorization was not 
obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 psychotherapy (90837) provided on August 5, 
2020 to August 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion services with CPT codes 99601 and 99602 
provided on June 1, 2020. 
 
You asked the Plan to pay for CPT codes 99601 and 99602. 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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, CPT codes 99601 and 99602 have a status code of "I" 
under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. 
Medicare uses another code for reporting of, and payment for, these services. Therefore, we decided that the 
Plan does not have to pay for the home infusion services with CPT codes 99601 and 99602 provided on June 1, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical services provided on May 20, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you did not receive a surgical 
procedure. The Plan denied your request. The Plan says you are liable for a routine radiology copay. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copay for x-rays.  
 
The file shows that the Plan has agreed to waive the copay for the outpatient surgery services billed on May 20, 
2020. You have been asked to pay a $20 copay for the vein x-ray you received. The x-ray falls within the 
outpatient diagnostic tests 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 copay for the medical 
services provided on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 27, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you only called to follow-up and 
feel that the charges are fraudulent. 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 $45 
copayment for specialist visits.  
 
The medical records show that you had a specialist visit via telehealth on July 27, 2020. Therefore, you are 
responsible to pay the $45 copayment.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 specialist visit provided on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the respiratory infectious agent detection (CPT 87633) 
provided on May 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee is an 86-year-old woman with a listed diagnosis of "Encounter for observation for 
suspected exposure to other biological agents ruled out." Testing was done to detect 19 distinct viral targets, 
excluding SARS-CoV-2. The case file does not contain clinical records supporting that infectious agent 
detection by nucleic acid was medically reasonable and necessary for the enrollee 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the respiratory infectious agent detection (CPT 87633) provided on May 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET brain imaging (78608). 
 
You asked the Plan to pre-approve the PET. You say that you would like reconsideration because this service is 
medically necessary. The Plan denied your request. The Plan says this service is not indicated per Medicare's 
NCD. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET. Our reviewer says that the 
member does not meet criteria for both AD and FTD. Our physician reviewer found it cannot be said that the 
member has a condition for which Medicare covers the requested service. 
 
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 PET have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET brain imaging (78608).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for molecular genetic hereditary predictive screening testing 
provided to the enrollee on February 26, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a request for a genetic UTI molecular pathogen ID test was made. This test is not supported with current 
evidence and would not effectively lead to an improvement in treatment success for this patient beyond the 
standard testing methods, based on the provided documentation. Therefore, the UTI molecular pathogen ID test 
will be considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for molecular genetic hereditary predictive screening testing provided to the enrollee on February 26, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360? molecular pathology genomic profiling 
provided to the enrollee on June 30, 2020. 
 
You asked the Plan to pay for the profiling. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for prostate cancer, 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare 
rules for coverage of the profiling have not been met. Therefore, we decided that the Plan does not have to pay 
for the Guardant360? molecular pathology genomic profiling provided to the enrollee on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to 
the enrollee on June 25, 2020. 
 
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 Comprehensive Genomic Profile (CGP) testing (i.e. Guardant-360' and NEXT-Generation') 
requires use of CPT 81479. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Percutaneous Vertebral Augmentation (PVA). 
 
You asked the Plan to pre-approve PVA. You say that the requested PVA is medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet criteria for the requested Percutaneous Vertebral 
Augmentation (PVA). 
 
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 PVA. Our reviewer says that the 
enrollee does not meet criteria for the requested Percutaneous Vertebral Augmentation (PVA). Our physician 
reviewer found this enrollee presents with complaints of severe unrelenting mid and low back pain subsequent 
to a recent fall. Functional limitations are noted in all activities of daily living. There is imaging evidence of an 
acute T9 compression fracture, chronic T11 and L2 compression fractures, and acute right sacral ala 
insufficiency fracture. She has failed to improve with recent conservative treatment, including rest, heat, and 
bracing. She has been approved for kyphoplasty at the T9 level. Under consideration is a request for T11 and 
L2 kyphoplasty. Medicare criteria have not been met in the setting of a chronic compression fracture. 
Therefore, the enrollee does not have a covered indication for percutaneous vertebral augmentation at T11 and 
L2. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PVA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Percutaneous Vertebral Augmentation (PVA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment (HCPCS A9279) provided to the 
enrollee on April 12, 2020 to May 12, 2020. 
 
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 HCPCS A9279 is all-inclusive, and is to be used whether the monitoring technology is 
incorporated as part of the base item, supplied as an add-on module or is a stand-alone item. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code A9279 is not supported in the medical record. Specifically, this code is bundled into 
payment for other codes, and is not covered when billed alone. 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 durable medical equipment (HCPCS A9279) provided to the enrollee on April 12, 2020 to May 
12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex spacer (22867, 22868) and associated inpatient 
hospital stay. 
 
You asked the Plan to pre-approve a Coflex spacer and associated inpatient hospital stay. You say that the 
services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
Therefore, coverage criteria has not been met. 
 
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 Coflex spacer and associated inpatient 
hospital stay. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Coflex spacer remains experimental. More research is 
needed to show safety and efficacy of the device. It is not medically needed in this case. There is no 
documented spinal instability. 
 
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 Coflex spacer and associated inpatient hospital stay have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Coflex spacer (22867, 22868) and 
associated inpatient hospital stay.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology genomic profiling 
provided to the enrollee on May 9, 2020. 
 
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 Medicare requires use of CPT 81479 to report a Guardant360? molecular pathology genomic 
profiling for NSCLC. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 Guardant360? molecular pathology genomic profiling provided to the enrollee on May 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a portable liquid oxygen system (E0433) provided on March 
17, 2020. 
 
You asked the Plan to pay for the portable liquid oxygen system. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says this is not a 
Medicare covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the portable liquid oxygen system have not been met. Specifically, the record indicates that this 
equipment was purchased by the member and is therefore not a covered benefit. Therefore, we decided that the 
Plan does not have to pay for a portable liquid oxygen system (E0433) provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction provided on June 8, 2020.
You asked the Plan to pay for the eye refraction. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received by the enrollee were not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Eye refractions are covered during a routine exam. Review of the file shows that the enrollee did not receive the eye refraction from the Provider. Based on this information, we decided that the
Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction provided on June 8, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided in an 
ambulatory surgical center on June 8, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic colonoscopy. 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 a diagnostic colonoscopy in an ambulatory surgical center on 
the date 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 $250 
copayment for Outpatient surgery provided in an ambulatory surgical center.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received a diagnostic 
colonoscopy, which included a surgical polyp removal, in an ambulatory surgical center on June 8, 2020. You 
have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls 
within the Outpatient surgery 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 
diagnostic colonoscopy provided in an ambulatory surgical center on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee would be better served in a slower paced, less intensive 
rehab program. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COPD exacerbation 
and atrial fibrillation. The enrollee's medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks (64635, 64636). 
 
You asked the Plan to pre-approve facet blocks. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Thermal Medial Branch Radiofrequency Neurotomy 
(includes RF and microwave technologies) is covered when specific criteria is met. 
 
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 facet blocks. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided medical records do not 
document that the enrollee has satisfied the requirements. Therefore, this procedure is not medically necessary 
and reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet blocks (64635, 64636).