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

 
We decided that the Plan does not have to pre-approve sacroiliac joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the doctor's notes do not show at least three findings that show that the pain is from the 
sacroiliac joint area. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found as there is clear overlap between these two pathologies regarding location and nature of pain, it makes 
sense to treat the primary problem (facet disease) prior to injection of the sacroiliac joint as there has been 
noted benefit from this procedure (facet joint injection). Therefore, coverage for the requested procedure, 
injection of the sacroiliac joint is not medically reasonable and 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug services rendered on 
March 12, 2020 and March 23, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you did not receive treatment on 
these dates. The Plan denied your request. The Plan says the coinsurance was applied correctly. 
 
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 20% of 
the allowed amount for in-network Medicare-covered Part B drugs and their administration.  
 
Review of the file shows that you received Part B drug injection services on March 12, 2020 and March 23, 
2020. You have been asked to pay 20% of the allowed amount for these services. These services fall within the 
in-network Medicare-covered Part B drugs and their administration 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 the Part B drug services rendered on March 12, 2020 and March 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transtibial prosthesis coded as L5785, L5668, 
L5629, L5645, L8420. 
 
You asked the Plan to pre-approve the transtibial prosthesis. You say that the requested special features do 
serve a medical purpose and are part of the design of the requested leg brace. The Plan denied your request. 
The Plan says the enrollee has a right partial foot amputation. The enrollee does not have a below the knee 
amputation. Therefore, the request for the below the knee components is not reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the transtibial prosthesis have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the transtibial prosthesis coded as L5785, L5668, L5629, L5645, L8420.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee out of 
network on March 2, 2020. 
 
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. 
The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract states outpatient mental health care requires a 
referral.  
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 outpatient mental health care provided to the enrollee out of network on March 2, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 16, 2019.
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 documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed code cannot be verified.
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 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 HCPCS G0482: 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; 15-21 drug class(es), including metabolite(s) if performed 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation does not contain a valid physician order or requisition that supports the denied codes. 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 drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on September 16, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a partial knee replacement for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that the records show a BMI that is above what is recommended (36).
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 procedure. Our reviewer says that the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with persistent severe bilateral knee pain. Functional limitations are noted in activities of daily living and ambulatory tolerance. Clinical exam findings document neutral alignment and are consistent with radiographic evidence of isolated severe patellofemoral joint arthritis. She has failed long-term reasonable and/or comprehensive operative and non-operative treatment. Under consideration is a request for left patellofemoral joint replacement. Current evidence based medical literature supports patellofemoral arthroplasty in this enrollee's medical condition. Although her body mass index is elevated above 30, current literature also states that obesity in itself is not a reason for surgical denial. There are no other contraindications to surgery. Therefore, this request for partial knee replacement. is 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve a partial knee replacement for the enrollee.
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
provided from May 7, 2019 to May 28, 2019. 
 
You asked the Plan to waive the copayment for the SNF services. The Plan denied your request. The Plan says 
that you are financially liable for the cost sharing. 
 
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 $172 
copayment per day for days 21-100 of SNF care.  
 
You have been asked to pay a $2,210 copayment for the SNF services. The SNF services falls within the days 
21-100 of SNF care benefit category. The file indicates you were in a SNF from April 19, 2019 through May 1, 
2019 and May 7, 2019 through May 28, 2019. You were in a SNF for a total of 35 days and owe a copayment 
of $172 for fifteen days. This means that you have been asked to pay less than 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 skilled nursing 
facility (SNF) services provided from May 7, 2019 to May 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a chest x-ray (71046) provided December 3, 2019. 
 
You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the primary payer is liable for payment. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary payer. As the secondary insurer, the Plan cannot be held responsible 
for the chest x-ray until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for a chest x-ray (71046) provided December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the 
enrollee on May 6, 2019. 
 
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 documentation submitted did not include a physician order/lab requisition or medical records 
stating exactly what tests are to be performed. 
 
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 G0483 is "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." 
 
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 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
submitted Laboratory Requisition indicates that Drug Abuse Panel 10-51 was requested. The submitted 
documentation does not itemize what tests are included in this panel; therefore, the billed code cannot be 
verified. The documentation submitted did not include a physician order/lab requisition or medical records 
stating exactly what tests are to be performed 
 
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 drug testing services (HCPCS G0483) provided to the enrollee on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on January 29, 2020.
You asked the Plan to pay for the drug test. 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 services 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 a drug test provided on January 29, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99284) February 
9, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were told the 
copayment would be discounted by the provider. The Plan denied your request. The Plan says the correct 
copayment was 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. the emergency room visit falls 
within the Emergency 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 
emergency room visit (99284) February 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on
December 19, 2019.
You asked the Plan to pay for the services. You say that the enrollee has Medicare policy, and under those
requirements no prior authorization is needed for genetic testing. The Plan denied your request. The Plan says
this provider is not a network provider.
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 genetic testing services provided to the enrollee on
December 19, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging 
with 4 or more additional parameters of sleep, attended by a technologist (95810). 
 
You asked the Plan to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more 
additional parameters of sleep, attended by a technologist. 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 repeat polysomnography or sleep testing for 
diagnosing sleep apnea requires documentation justifying the medical necessity for the repeated test. 
 
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 polysomnography; age 6 years or older, 
sleep staging with 4 or more additional parameters of sleep, attended by a technologist. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the request for a repeat diagnostic study 
(CPT 95810) would otherwise be considered to be redundant at this time. Only one CPT code is to be billed for 
on a given night of sleep testing. Even if a split-night polysomnography were to be performed, that is 
appropriately coded with CPT 95811. The enrollee has already been diagnosed with obstructive sleep apnea 
(OSA) and there is not otherwise a clinical indication to re-evaluate the primary diagnosis with a repeat 
baseline study (CPT 95810). In as much the service under review would be duplicative and therefore not 
eligible for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of polysomnography; age 6 years or older, sleep staging with 4 or more additional 
parameters of sleep, attended by a technologist have not been met. Therefore, we decided that the Plan does not 
have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters 
of sleep, attended by a technologist (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neuromuscular stimulator, electronic shock (NMES) 
unit (E0745). 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied 
your request. The Plan says the services are not 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 DME. Our physician reviewer 
found the medical records provided do meet the requirements listed in the LCD/PIM for Medicare coverage for 
neuromuscular stimulator, electronic shock (NMES) unit (E0745). There is no evidence that you require this 
device for the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal 
cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. There is no evidence that 
you have s a spinal cord injury and needs this device for walking after completing a training program which 
consists of at least 32 physical therapy sessions with the device over a period of three months. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve neuromuscular stimulator, electronic shock (NMES) unit (E0745).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January 13, 2020.
You asked the Plan to waive the copayment for these services. You say that the services were a post-surgical visit and should have no copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $25 copayment for in-network specialist's office services.
Review of the file shows that you received specialist services on January 13, 2020. You have been asked to pay a $25 copayment for these services. These services fall within the in-network specialist's office services 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.
The file shows that you had a surgical procedure on October 8, 2019. This procedure has a 90-day global surgical period; however, the services on January 13, 2020 fall outside of the 90-day global period.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on January 13, 2020.