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

We decided that the Plan does not have to pay for a psychotherapy visit provided by a clinical psychologist on 
March 4, 2021. 
 
You asked the Plan to pay for clinical psychologist visit. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
there was no documented contact with the attending/primary care physician and no referring provider is listed 
on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that a clinical psychologist must attempt to consult 
with the enrollee's attending or primary care physician upon consent to consultation with an enrollee. We looked at the file and Medicare rules. The record does not show that any consultation or attempt to consult 
with the enrollee's attending or primary care physician was made. Based on this information, we decided that 
Medicare rules for coverage of clinical psychologist visit have not been met. Therefore, we decided that the 
Plan does not have to pay for a psychotherapy visit provided by a clinical psychologist on March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97530) provided to the 
enrollee on June 12, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 97530 remains 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 code 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes." 
 
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 CPT 
code 97530 requires the use of dynamic activities to improve functional performance. Examples of such 
activities include lifting, pushing, pulling, reaching, and throwing. Such activities are not documented in the 
records provided. CPT 97530 was not the most appropriate code to use in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (CPT 97530) provided to the enrollee on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical spinal injection procedure 
provided on December 16, 2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were not made aware of 
this charge and if you had known of this high copayment, you would have sought another form of pain relief. 
The Plan denied your request. The Plan says the copayment amount you are 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). Your contract with the Plan clearly says that you must pay $395 
copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay $395 copayment for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a surgical spinal 
injection procedure provided on December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a pharmacogenomic panel (81230, 81231, 81240, 81241, 
81328, 81408) provided on July 29, 2020. 
 
You asked the Plan to pay for a pharmacogenomic panel. You say that this is supported in the records. The 
Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. If a laboratory assays two or more genes in a 
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel.  
 
We find that CPT codes 81230, 81231, 81240, 81241, 81328, and 81408 are not supported in the medical 
record. Specifically, the records show that the testing at issue was performed as a panel, meaning it should be 
reported with one code. Based on this information, we decided that Medicare rules for coverage of a 
pharmacogenomic panel have not been met. Therefore, we decided that the Plan does not have to pay for a 
pharmacogenomic panel (81230, 81231, 81240, 81241, 81328, 81408) provided on July 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on July 14, 2020. 
 
You asked the Plan to pay for therapeutic activities. You say that this should be covered at the in-network rate. 
The Plan denied your request. The Plan says this was not billed correctly. 
 
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 97530 is therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT code 97530 is not supported in the medical record. Specifically, the record shows that this 
service was provided in a home health setting. There is a more appropriate code for this service. Based on this 
information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided on July 14, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the drug is not being used for medically-accepted standards. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the review indicates 
that the requested Retacrit is being not being used under the medically-accepted standards of: recent 
Hemoglobin (Hgb) level less than 10.0 g/dL or Hematocrit (HCT) less than 30% within the last 4 weeks. the 
request does not meet Part B coverage criteria for the requested drug as the last documented hemoglobin was 
Hgb 11.0 from 4/27/2021. The review has determined that the documentation does not support that the drug is 
medically reasonable, safe, effective 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve portable ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the enrollee would greatly benefit from using 
the Trilogy nightly and even throughout the day. The Plan denied your request. The Plan says the enrollee does 
not meet the Medicare criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a diagnosis of COPD is indicated, but the pulmonary function tests do not support this. They 
indicate mild restrictive disease. The enrollee does not have neuromuscular disease or thoracic restrictive 
disease. This enrollee is reportedly on BiPAP with oxygen, and overnight oximetry shows desaturations. However, the oximetry report does not confirm that the enrollee was on oxygen for the test. There are no data 
on BiPAP compliance. Certain BiPAP devices can provide the AVAPS mode of ventilation, at much less cost 
than the ventilator, and Medicare does not cover a ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve portable ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 1, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that you paid your copayment for the eye exam and 
do not know why there is an additional bill or why this test was done. The Plan denied your request. The Plan 
says an eye refraction is considered a routine vision service that is not covered by Original Medicare. It can be 
covered under your supplemental routine vision benefit, however the provider in this case is not part of the 
routine vision network. Therefore, payment cannot be made. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a provider in the Plan's specified routine 
vision network. 
 
We looked at the file and the Plan's rules. This eye refraction was provided out of the Plan's routine vision 
provider network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction 
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) 
provided on March 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Perjeta and Herceptin provided on November 10, 2020. 
 
You asked the Plan to pay for Perjeta and Herceptin. You say that this was medically necessary. The Plan 
denied your request. The Plan says these drugs are experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Perjeta and Herceptin. Our reviewer says 
that the use of Perjeta and Herceptin at issue is not supported. Our physician reviewer found Perjeta and 
Herceptin are not FDA-approved for the enrollee's diagnosis. This use is also not supported by one of the 
major drug compendia or by clinical research. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Perjeta and Herceptin have not been met. Therefore, we decided that the Plan 
does not have to pay for Perjeta and Herceptin provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 16, 
2021. 
 
You asked the Plan to pay for the periodontal maintenance. You say that you have received reimbursement for 
services rendered by this provider in the past. The Plan denied your request. The Plan says the provider who 
rendered the services has opted out of Medicare and therefore the service is not covered. 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 
periodontal maintenance when provided by a licensed dental provider who accepts Medicare patients in the 
United States and has not opted out of Original Medicare 
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program.  Based on this information, 
we decided that the Plan's rules for coverage of the periodontal maintenance have not been met. Therefore, we 
decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided March 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, 
A0425) received February 26, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that it was not your 
decision to be transferred to a rehab facility. The Plan denied your request. The Plan says the correct cost share 
applied to the claim. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Ambulance Services.  
 
You have been asked to pay a $250 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for 
the ambulance transportation (A0428, A0425) received February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says this is 
maintenance therapy. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic services Our reviewer 
says that the requested chiropractic services are not medically reasonable and necessary in this case. Our 
physician reviewer found that no physical examination was performed to demonstrate subluxation. No imaging 
is provided. The services would not be reasonably expected to result in clinical improvement given the 
chronicity of the issue. The record does not indicate that subluxation is present. 
 
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 chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the 
enrollee on April 29, 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 this is not appropriate for 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 code 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 
 
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 
procedure code G0157 (Services performed by a qualified physical therapy assistant in the home health or 
hospice setting, each 15 minutes) would be a more appropriate code in this case. The physical therapy note 
contains documentation of Bed mobility Training, Transfer Training, Gait Training, Balance, and Fall Risk and Other Testing. The documentation does not support the billed 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for physical therapy services (CPT 97110) provided to the enrollee on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory test provided on March 29, 
2021. 
 
You asked the Plan to waive the deductible for the laboratory test. You say that under federal law health plans 
must covered the Cologuard test without cost sharing as an in-network service for patients who are 50 to 75 
years old. You say that you are requesting to overturn the processing of this claim, so you receive the in-
network benefit and the claim paid in full. The Plan denied your request. The Plan says the deductible applied 
correctly. The item or service you asked the Plan to waive the deductible for falls within the "Colorectal cancer 
screening" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that 
your $5,600 yearly deductible applies to colorectal cancer screenings. This cost sharing is a contractual 
obligation that had not been met at the time the laboratory test was received on March 29, 2021. Therefore, we 
decided that the Plan does not have to waive the deductible for the laboratory test provided on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not 
require transfer to the LTACH. 
 
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 that in this case the enrollee was admitted after being struck as a pedestrian by a 
motor vehicle and sustaining multiple trauma including traumatic brain injury and fractures. The enrollee 
continues to receive acute care services and these have not been denied.  The medical record does not indicate 
that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 
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 admission to a long term acute care hospital (LTACH).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 7, 
2020, to December 6, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care 
beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 6, 2020, 
to November 6, 2020. The Plan has covered 100 days of SNF care.  
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from November 7, 2020, to 
December 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on January 28, 2021, 
billed with codes 99601 and 99602. 
 
You asked the Plan to pay for the home infusions services as billed. You say that you believe that this is coded 
correctly and should be paid. The Plan denied your request. The Plan says this service is not billed using valid 
codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT codes 99601 and 99602 have status indicators of "I" in the Physician Fee Schedule. This means that they 
are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for 
coverage of the home infusions services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services provided on January 
28, 2021, billed with codes 99601 and 99602.