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

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on February 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network 
deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for proton beam therapy provided to the enrollee on December 
8, 2019. 
 
You asked the Plan to pay for the therapy. You say that this should be paid for. The Plan denied your request. 
The Plan says this type of therapy for anorectal cancer is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the therapy. Our reviewer says that the 
services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the 
records do not demonstrate, with a quantitative dosimetric rationale, that any of the above criteria are met. 
Proton therapy is not an accepted standard for routine radiation for anal or rectal cancers; with exceptional 
circumstances (such as prior irradiation or unusual anatomy) it can be considered medically necessary. For this 
enrollee, there is no plan comparison showing an appreciable benefit. The treatment of this enrollee with proton 
therapy would not be furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for proton beam therapy provided to the enrollee on December 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that 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 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. Our 
physician reviewer found the enrollee was admitted for treatment of subarachnoid hemorrhage. The enrollee 
was weaned from ventilator support. The enrollee's medical problems are stable. The documentation does 
support that the enrollee requires additional physical therapy and occupational therapy, but does not show that 
the enrollee requires an intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on 
March 2, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the copay for outpatient surgery 
is listed as $100. The Plan denied your request. The Plan says the claim for services was billed as an outpatient 
hospital, not an ambulatory surgical facility. 
 
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 $195 
copay for surgery services in an outpatient hospital.  
 
You have been asked to pay a $195 copay for the services provided. The annual notice of change and the 
Evidence of Coverage shows that you pay a $100 copay when you receive outpatient surgery at an ambulatory 
surgical center. However, the documentation shows that you received surgery services at an outpatient hospital 
facility. The services fall 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 copay for the outpatient surgery services provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 3, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the testing 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 test at issue in this appeal, C-reactive protein, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes.  
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 3, 
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 can safely receive the services needed in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
patient is medically stable after an uncomplicated hip fracture with no evidence of need for supervision by a 
physical medicine and rehab physician or need for acute rehab nursing care. Functionally she needs physical 
therapy (PT) and occupational therapy (OT) but does not require IRF level of therapies. The patient may 
benefit from further PT and OT but does not require an intensive therapy program. IRF admission is not 
medically necessary based on the patient's lack of medical complexity. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on May 13, 2019. 
 
You asked the Plan to pay for drug test. You say that this testing was ordered by the enrollee's treating 
physician and was provided in good faith. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because no clinical information was submitted to support this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit to the Plan sufficient 
information to determine whether payment is due for the claim.  
 
We looked at the file and Medicare rules. You did not submit medical records to the Plan to support the service 
billed. The Plan requested this information, but it was not provided. Without this information, you have not 
furnished sufficient information to the Plan to determine that payment is due for the testing as billed on this 
claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. 
Therefore, we decided that the Plan does not have to pay for drug testing provided on May 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has had multiple falls. The Plan 
denied your request. The Plan says the enrollee does not require skilled services on a daily basis. 
 
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 services. Our physician reviewer 
found that from a nursing perspective, the enrollee received oral medications, and had stable vital signs. There 
are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a maximal assist 
level with functional mobility. She required varying assist with activities of daily living. There are no 
identifiable skilled therapy service needs. She does not require skilled nursing or therapy services on a daily 
basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
SNF setting. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the eye injection and the Part B drug 
provided on February 4, 2020. 
 
You asked the Plan to reduce the cost share for the eye injection and the Part B drug. You say that your doctor 
is listed as in-network and you have only had to pay around $15 in the past.  The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $35 copayment for surgery services at an in-network specialist's office and 20% coinsurance for in-
network Medicare Part B covered drugs.  
 
The enrollee has been asked to pay a total of $51.13 for the eye injection and the Part B drug. The eye injection 
falls within the Physician/Practitioner services, including doctor's office visits benefit category. The Part B 
drug falls within the Medicare Part B prescription drugs benefit category. The record shows that the claim 
processed according to your in-network benefits. See chart below. 
  
 
Date of Service Service Allowed Amount Coinsurance/Copayment Member 
Liability 
February 4, 2020 Eye injection $100.08 $35.00 $35.00 
February 4, 2020 Part B drug $80.64 20% $16.13 
Total    $51.13 
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to reduce the cost share for the eye injection and the Part B drug provided 
on February 4, 2020. 
 
Our decision is only about the February 4, 2020 services. If you have any questions about prior years billing, 
please contact the plan directly.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
November 26, 2019. 
 
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom 
profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order 
or medical records stating exactly what tests are to be performed. 
 
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 find that testing at issue is not supported in the medical record. There is no evidence that shows the test was 
individualized to identify specific non-prescribed medications or illicit substances. The records provided do not 
document concerns based on clinical review and judgement. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for 
the presumptive and definitive drug testing provided on November 26, 2019.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health care supervision (G0181) provided on January 31, 2020. 
 
You asked the Plan to pay for home health care supervision. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that this evaluation and management 
service is not allowed separately when a transitional care management service has already been allowed 30 
calendar days prior to this billed date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not forward sufficient information to show that the transitional care 
management code was approved and paid. Therefore, we decided that the Plan has to pay for home health care 
supervision (G0181) provided on January 31, 2020. 
  
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 waive the copayment for an outpatient hospital clinic visit provided 
on December 16, 2019. 
 
You asked the Plan to waive the copayment for clinic visit. You say that you are appealing this charge. The 
Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay $200 copayment for outpatient hospital clinic visit.  
 
The enrollee has been asked to pay the allowed amount of $120.67, which is less than the $200 copayment for 
clinic visit. Clinic visit falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for an outpatient hospital clinic visit provided on December 16, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the presumptive and definitive drug testing provided on July 25, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan 
denied your request. The Plan says that this claim was billed with POS code 11 but the submitted medical 
documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation 
setting POS 57. Also, there is no evidence that the enrollee has ever seen the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code should reflect the location in which 
the sample was taken for lab services. The rules also say that lab testing must be ordered by a treating provider. 
 
In this case, we find no evidence that the POS code reported is incorrect. In addition, the ordering provider is 
in-network with the Plan and if a Plan provider is ordering testing for a Plan enrollee without seeing the 
enrollee, the Plan must work with that provider to rectify the situation. Therefore, we decided that the Plan has 
to pay for the presumptive and definitive drug testing provided on July 25, 2019.  
 
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 surgical pathology services provided to the enrollee on 
December 9, 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 denied codes remain not supported. 
 
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 88305: 
 
Level IV - Surgical pathology, gross and microscopic examination 
 
CPT 88312: 
 
Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine 
silver) 
 
CPT 88313: 
 
Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for 
microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.  
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found in terms of 
CPT 88305 - the toenail is not a listed specimen for surgical pathology, service level is based on comparable 
physician work. Per operative report "The nails were debrided 1 through 10". Per level lV Skin, other than 
cyst/tag/debridement/plastic repair is listed. There is a more accurate code to describe this procedure. For CPT 
88312 and 88313 - the documentation in the procedure does not include documentation of Special Stain 
including interpretation and report to verify group of stain used and also to verify units. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical pathology services provided to the enrollee on December 9, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the emergency room (ER) services 
rendered on October 19, 2019. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
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 a 0% or 
20% coinsurance (up to $120) for each Medicare-covered emergency room visit.  
 
Review of the file shows that you received ER services on October 19, 2019. You have been asked to pay a 0% 
or 20% coinsurance (up to $120) for these services. The Plan applied the $120 benefit maximum to these 
services, given that the total charge was $6,833.08. These services fall within the Medicare-covered emergency 
room visit 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 emergency room (ER) 
services rendered on October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rocklatan eye drops. 
 
You asked the Plan to pre-approve Rocklatan. You say that the enrollee's intraocular pressure has improved 
using Rocklatan. The Plan denied your request. The Plan says this drug is not covered for the enrollee's 
condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rocklatan eye drops.  
 
Benefits for Rocklatan may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.