Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health inpatient treatment. 
 
You asked the Plan to pre-approve mental health inpatient treatment. 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 mental health inpatient treatment. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found based upon review of the records provided, the enrollee does not meet the 
criteria for continued acute inpatient mental health treatment for the dates in question of October 16, 2020 
forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or 
visual hallucinations and was cooperative/compliant with treatment while not showing any threats to the safety 
of herself or others as she awaits guardianship and placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mental health inpatient treatment have not been met. Therefore, we decided that 
the Plan does not have to pre-approve mental health inpatient treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (87150, 87500, 87640, 87653, 87798, 
87799) provided on June 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that your lab performed all the tests that were ordered by 
the referring physician. The Plan denied your request. The Plan says prior authorization must be obtained for 
non-emergent services rendered by an out-of-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 the genetic testing (87150, 87500, 87640, 87653, 
87798, 87799) provided on June 4, 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 intensive cardiac rehabilitation (G0422, G0423) provided 
on February 11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the intensive cardiac rehabilitation. You say that you would like this claim 
reprocessed and approved for payment. 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 intensive cardiac rehabilitation (G0422, 
G0423) provided on February 11, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels. 
 
You asked the Plan to pre-approve a combination sit to stand frame/table system (E0637). You say that because 
of your medical condition you need this device to assist you to stand. The Plan denied your request. The Plan 
says the stander would not reasonably be expected to improve your condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Sit to stand systems 
are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a 
combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without 
wheels.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 
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. 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 drug testing services provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on March 13, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z identifier must be entered adjacent to the code in 
the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on March 13, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Supartz injection (CPT code J7321). 
 
You asked the Plan to pre-approve the medication. You say that this is a suitable match for the patient. The 
Plan denied your request. The Plan says Part B step therapy criteria are not met 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the provided records did not clearly show that the right knee had osteoarthritis nor that the patient had 
failed conservative methods such as exercises and weight loss nor that she had failed steroid injection to the 
right knee. Also, the records did not show that the patient had tried and failed Synvisc, Durolane, or Gelsyn-3. 
As each of the hyaluronic acid derivatives have been shown to have essentially equal effectiveness and safety 
outcomes, it is unlikely that any of the above preferred agents would likely be less effective and/or likely have 
adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Supartz injection (CPT code J7321).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a total electric hospital bed from April 25, 2020 to June 24, 
2020. 
 
You asked the Plan to pay for a total electric hospital bed. You say that a total electric hospital bed was 
medically necessary and should be covered by the Plan. The Plan denied your request. The Plan says total 
electric hospital beds are not covered by the Plan or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed 
from April 25, 2020 to June 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the office visit and ultrasounds provided 
on January 9, 2020. 
 
You asked the Plan to reduce the copayment for the office visit and ultrasounds. You say that for the past 11 
years your copayment has been $20 for each procedure. You say that you believe there has been a mistake in 
coding and the charges should be adjusted. The Plan denied your request. The Plan says the copayments 
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 $20 
copayment for services obtained from a specialist and a $155 copayment for each Medicare-covered 
radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing 
facility. 
You have been asked to pay a total of $119.10 for the office visit and ultrasounds. 
 
Service Allowed Amount Standard Copayment Member Liability 
Office Visit $67.88 $20 $20 
Ultrasounds $99.10 $155/ultrasound $99.10 
TOTAL:   $119.10 
 
The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit 
category. The ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
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 reduce the copayment for the office visit and ultrasounds 
provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of a ruptured Achilles tendon (27650) provided. 
 
You asked the Plan to pay for the repair of a ruptured Achilles tendon. You say that this is supported in the 
medical records. The Plan denied your request. The Plan says this code is not supported by the billed diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 27650 is repair, primary, open or percutaneous, ruptured 
Achilles tendon. 
 
We find that CPT code 27650 is not supported in the medical record. Specifically, this code was billed with a 
diagnosis of M76.62, Achilles tendinitis, left leg, which does not indicate a ruptured Achilles tendon. Based on 
this information, we decided that Medicare rules for coverage of the repair of a ruptured Achilles tendon have 
not been met. Therefore, we decided that the Plan does not have to pay for the repair of a ruptured Achilles 
tendon (27650) provided.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided on 
January 13, 2020 to January 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that you were unaware prior 
authorization was required. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-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 the psychiatric diagnostic evaluation (90791) 
provided on January 13, 2020 to January 27, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services, including skilled nursing visits, 
physical and occupational therapy, and medical social services. 
 
You asked the Plan to pre-approve the home health services. You say that home health care is required for this 
enrollee. The Plan denied your request. The Plan says there is insufficient evidence to show that these services 
are medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that based on the limited documentation provided, the medical necessity of the requested home health 
services is not supported. Our physician reviewer found the enrollee is reported to have chronic right shoulder 
pain. No objective evaluation of her shoulder is documented. The enrollee is not noted to be home bound, as 
evidenced by her ability to attend an in-office medical appointment. The documentation does not support that 
either rehabilitative services or in-home services are currently medically necessary or 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 the home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services, including skilled nursing visits, physical and occupational 
therapy, and medical social services.
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 it is in the enrollee's best interest to 
transition so she can maximize her full recovery potential. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient care, and does not require transfer. 
 
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 physician 
reviewer found that the enrollee as admitted to the current acute care hospital with shortness of breath, cough, 
diarrhea, and weakness related to COVID-19 pneumonia and a urinary tract infection. She was diagnosed with 
hemothorax. Improvement in breathing status, hemothorax, vitals, and gradual reduction in the white blood 
count was noted in recent notes. The enrollee appears to need more time in the acute care hospital to further 
stabilize, although current improvement suggests a likely need for less than an additional 25 days. The enrollee 
does not require services at the LTACH that are not already available at the current facility. Therefore, this 
request for LTACH services will be considered not medically necessary at this time. 
 
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on April 28, 2020.You asked the Plan to waive the copayment for an x-ray. You say that you were inpatient at this time. The Plan denied your request. The Plan says the x-ray was provided before the enrollee was formally admitted.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 $235 copayment for outpatient diagnostic tests/in-network/diagnostic test. You have been asked to pay $71.57 which is less than your copayment amount of $235 for an x-ray. This service was provided as an outpatient; therefore, the correct copayment has been applied. An x-ray falls within theoutpatient diagnostic tests/in-network/diagnostic test 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 x-ray provided by a participating provider on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that treatment that can be provided elsewhere such as in a skilled 
nursing facility. 
 
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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The documentation 
does not support that the enrollee in this case requires services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 26, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges. 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 $20 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay a $20 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests and therapeutic services and supplies 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 ultrasound provided on May 26, 2020.