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

 
We decided that the Plan does not have to pay for the drug testing services provided on January 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 13, 2019. 
 
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 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 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 laboratory services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services provided on May 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on October 18, 2019 to November 
29, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that these provided was in-network. The Plan denied 
your request. The Plan says prior authorization was not obtained. 
 
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 physical therapy provided on October 18, 2019 to 
November 29, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that the enrollee's condition will not go away, but with effective airway clearance there can be a decreased risk for respiratory exacerbation's, expensive hospitalizations, and worsening symptoms. You say that the requested device is medically necessary. The Plan denied your request. The Plan says that the notes sent do not show that the enrollee has problems clearly secretions and that the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 

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 HFCWOD. Our physician reviewer found coverage criteria are met for HFCWO. This patient has carnitine palmitoyltransferase (CPT) deficiency, a genetic myopathy that causes generalized muscular weakness. The patient is having difficulty clearing secretions, and has a productive cough of more than six (6) months.  Hypertonic saline and acapella have not been effective, and the patient does not have a caregiver to provide CPT. HFCWO is considered medically necessary, and the denial is overturned.

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 HFCWOD have been met. Therefore, we decided that the Plan has to pre-approve a high frequency chest wall oscillation device (HFCWOD). 

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 pay for the lab services provided on January 28, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code E1399 that 
were issued on March 23, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that the claim should be paid. The Plan 
denied your request. The Plan says these compression socks are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code E1399 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code E1399 that were issued on March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on March 6, 2020 to March 8, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not know why 
you are being charged this amount. 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 $295 
copayment per day for days 1-7. There is a $0 copayment for additional days each day for inpatient hospital 
care.  
 
You have been asked to pay a $295 copayment per day for an inpatient hospital stay. The total amount you are 
being asked to pay is $590 ($295 x 2 days = $590). An inpatient hospital stay falls within the inpatient hospital 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay 
provided by a participating provider on March 6, 2020 to March 8, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says that a CT scan is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that a 
CT scan of the heart is medically reasonable and necessary for the enrollee in this case. Our physician reviewer 
found that given the enrollee's advanced age and mildly elevated LDL cholesterol, even assuming no other risk 
factors for cardiovascular disease, his 10 year CVD risk is 17%. This would put him in the category to strongly 
consider statin therapy. However, in the absence of known CAD, he could safely be managed without statin 
therapy if his coronary calcium score was zero or very low. For this reason, a coronary calcium CT scan 
without contrast to further refine his CVD risk, especially when statin therapy is being considered, is medically 
reasonable and necessary, and supported by published 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 CT scan have not been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the heart.  
 
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 CPT Code E2311, CPT Code E2377, CPT Code E2313,
and CPT Code E2300.
You asked the Plan to pre-approve the accessories. You say that you are requesting review of denial of
accessories. The Plan denied your request. The Plan says there is not a medical need to control these power
options through the joystick.
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 accessories. Our physician reviewer
found based on review of available records, the patient does not meet criteria for coverage for the items at
issue. Our physician agreed with the previous reviewers' assessment that a seat lift does not serve a medical
purpose and cannot be covered. The upgraded electronics (expandable controller, harness and electronic
connector to 2 power options) are not medically necessary. They are needed when there is a medical need to
control power options though the joystick. The notes do not show a medical need to control the power options
through the joystick. The power options can be controlled using their own switches.
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 accessories have not been met. Therefore, we decided that the Plan does not
have to pre-approve CPT Code E2311, CPT Code E2377, CPT Code E2313, and CPT Code E2300.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip arthroplasty (27130). 
 
You asked the Plan to pre-approve a total hip arthroplasty. You say that this is necessary so the enrollee can 
return to normal activities of daily living. The Plan denied your request. The Plan says the enrollee has not tried 
conservative treatment. 
 
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 total hip arthroplasty. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation of adequate conservative measures to include recent 
physical therapy for hip pain. More conservative measures are needed before a total hip arthroplasty can be 
considered 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 a total hip arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip arthroplasty (27130).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need electronic care and constant 
wound care. The Plan denied your request. The Plan says LTACH services are 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 provided shows that you require short-term additional acute care 
services. Also, the clinical status does not suggest a likely need for acute care services for at least 25 days. You 
do not require any services at the LTACH that are not already available at the current facility. 
 
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 long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable oxygen contents provided on May 29, 2020. 
 
You asked the Plan to pay for the portable oxygen contents. 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 
portable oxygen contents. We found no exception that would require the Plan to pay for these items. Therefore, 
we decided that the Plan does not have to pay for portable oxygen contents provided on May 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating 
provider on March 10, 2020 to April 7, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you were quoted for $202. You 
say that now you are receiving bills for thousands of dollars. The Plan denied your request. The Plan says the 
correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for chemotherapy. The total allowed 
amount is $10.325.35. The total amount you are being asked to pay is $2,065.09 ($10,325.35 x 20% = 
$2,065.09). Chemotherapy falls within the Medicare Part B prescription drugs 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 coinsurance for chemotherapy provided by a participating provider on March 10, 
2020 to April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Radiation therapy (PBT) (77523, 77387, 
77301). 
 
You asked the Plan to pre-approve PBT. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not shown to be safe and effective. 
 
The Plan follows Medicare rules. Medicare rules say that PBT is considered reasonable in instances where 
sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of 
added clinical benefit to the patient. 
 
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 PBT. Our reviewer says that the records 
do not show PBT is medically necessary in this case. Our physician reviewer found the case file lacks any 
specific dosimetric rationales for the need of proton therapy in this specific patient that would translate into a 
plausible clinical benefit. The criteria for coverage have not been met and other potentially equally efficacious 
forms of radiotherapy are available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Radiation therapy (PBT) (77523, 77387, 77301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed bridge replacing teeth 18, 19 and 20 with pontics 
(D6240) using teeth 17 and 21 as retainers (D6750). 
 
You asked the Plan to pre-approve the fixed bridge. You say that the service is medically necessary. The Plan 
denied your request. The Plan says a fixed bridge is covered if replacing a single maxillary anterior tooth or 
two mandibular anterior teeth and no posterior teeth missing. 
 
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. The Plan covers the fixed 
bridge when the services are medically necessary and reasonable.  
 
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 fixed bridge. Our reviewer says that 
coverage criteria is not met. Our physician reviewer found the bridge is not for the purpose of replacing a 
single maxillary anterior tooth or two mandibular teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a fixed bridge replacing teeth 18, 19 and 20 with pontics (D6240) using teeth 17 and 
21 as retainers (D6750).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on January 31, 
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 the records do not support the services 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 81057: 
 
Carbamepazine; free 
 
CPT 80159: 
 
Clozapine 
 
CPT 80162: 
 
Digoxin; total 
 
CPT 80173: 
 
Haloperidol 
 
CPT 80177: 
 
Levetiracetam 
 
CPT 80201: 
 
Topiramate 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
 
We find that the denied codes are not supported in the medical record. Specifically, there is no valid physician 
order for these services, and the services were done by urine sampling rather than blood sampling. 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 drug testing services provided to the enrollee on January 31, 
2020.