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

We decided that the Plan does not have to waive the coinsurance for the tissue pathology tests provided on 
January 21, 2020. 
 
You asked the Plan to waive the coinsurance for the tissue pathology tests. You say that this should be covered 
in full by insurance. 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). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for laboratory tests.  
 
You have been asked to pay $68.78 which is 20% of the allowed amount for the tissue pathology tests. The 
allowed amount is $343.89. ($343.89 x 20% = $68.78). The tissue pathology tests fall within the ?Outpatient 
diagnostic tests and therapeutic services and supplies? benefit category. The record shows you were billed 
separately for the tissue pathology tests. 
 
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 tissue pathology tests provided on January 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an echocardiography ultrasound 
examination (93351) provided on February 11, 2020. 
 
You asked the Plan to waive the copayment for an echocardiography ultrasound examination. You say that this 
should be covered at the lower non-radiological copayment. The Plan denied your request. The Plan says this 
processed 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 $160 
copayment for radiological diagnostic services such as ultrasounds.  
 
You have been asked to pay a $160 copayment for an echocardiography ultrasound examination. 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 echocardiography ultrasound examination (93351) provided on 
February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 5, 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 procedure codes 81225-90, 81226-90, 81227-90, 81230-90, 81231-90, 81240-90, 
81241-90, 81328-90, 81335-90, 81232-90, 81283-90 and 81408-90 are 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 81408 is molecular pathology procedure, Level 9. The 
definition of code 81225 is CYP2C19 gene analysis. The definition of code 81226 is CYP2D6 gene analysis. 
The definition of code 81227 is CYP2C9 gene analysis. The definition of code 81230 is CYP3A4 gene 
analysis. The definition of code 81231 is CYP3A5 gene analysis. The definition of code 81232 is DPYD gene 
analysis. The definition of code 81240 is F2 gene analysis. The definition of code 81241 is F5 gene analysis. 
The definition of code 81283 is IFNL3 gene analysis. The definition of code 81328 is SLCO1B1 gene analysis. 
The definition of code 81335 is TPMT gene analysis. 
 
We find that CPT codes 81225-90, 81226-90, 81227-90, 81230-90, 81231-90, 81240-90, 81241-90, 81328-90, 
81335-90, 81232-90, 81283-90 and 81408-90 are not supported in the medical record. Specifically, there are no 
laboratory results to support these codes were performed. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the laboratory services rendered on February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that on the date of service the enrollee fell and 
an ambulance was called by the staff of the enrollee's residence. You say that the responders examined the 
enrollee and had left before your daughter arrived. You stated that the enrollee needed an MRI because she had 
hit her head when she fell, and the enrollee's granddaughter took her to the hospital. You asked the Plan to 
reprocess the claim and consider providing coverage for the services since neither you nor the enrollee had 
called for the ambulance. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 21, 2019. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a shoulder x-ray (73020) provided on December 20, 2019. 
 
You asked the Plan to pay for the shoulder x-ray. You say that you would like reconsideration because this is a 
corrected claim, not a new claim. The Plan denied your request. The Plan says that the documentation provided 
did not utilize the appropriate modifier showing that these procedures were distinct and independent to one 
another. 
 
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 73020 is radiologic examination, shoulder; 1 view. 
 
We find that CPT code 73020 is supported in the medical record. Specifically, the record indicates that a 
radiologic examination, shoulder; 1 view was rendered on the billed date of service. Based on this information, 
we decided that Medicare rules for coverage of the shoulder x-ray have been met. Therefore, we decided that 
the Plan has to pay for a shoulder x-ray (73020) provided on December 20, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee cannot 
tolerate intensive daily therapy. 
 
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 physician reviewer found 
that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a 
biliary mass. There were no complications in the provided procedure. His medical conditions are stable. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the record supports a need for physical and 
occupational therapy, the patient's endurance is described as poor and the record does not plausibly support that 
the he has the ability to participate in an intensive rehabilitation program. Therefore, the requested services are 
not 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 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice long term care services (code T2046) provided 
from January 1, 2020 to January 31, 2020. 
 
You asked the Plan to pay for the long term care services. You say that when you entered authorization 
information, it stated that authorization was not required for this service. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare 
purposes and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospice long term care services (code T2046) provided from January 1, 2020 to January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
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. 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 on August 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D rendering and interpretation rendered on February 26, 
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 procedure code 76376 is 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 76376 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
postprocessing under concurrent supervision; not requiring image postprocessing on an independent 
workstation. 
 
We find that CPT code 76376 is not supported in the medical record. Specifically, there is no documentation of 
3D rendering and billing of an appropriate base radiology procedure. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the 3D rendering and interpretation rendered on February 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 23, 
2019 through January 20, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this code is not for durable medical equipment and that the medication is delivered to the provider's office and 
not the member's home. The Plan denied your request. The Plan says this code is not payable by Original 
Medicare. 
 
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 CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) 
provided on October 23, 2019 through January 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after August 7, 2020.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 continued SNF coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had stable vital signs. You required minimal to moderate assistance with functional mobility including walking to 20 feet with a rolling walker. You required varying assistance with activities of daily living. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF level 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 continued SNF coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on February 27, 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 blood specimen collection is by venipuncture, however, the lab results indicate a urine specimen was tested.

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 80157:

Carbamazepine; free testing

CPT 80177:

Levetiracetam testing

CPT 80201:

Topiramate testing

CPT 80162:

Digoxin; total testing

CPT 80159:

Clozapine testing

CPT 80173:

Haloperidol testing

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 the laboratory lists urine as source of testing.  Per the CPT guidelines; Therapeutic Drug Assays are performed to monitor clinical response to a known, prescribed medication. The material for examination is whole blood, serum, plasma, or cerebralspinal fluid. Examination is quantitative, Coding is by parent drug; measured metabolites of the drug are included in the code, if performed. Laboratory only specifies urine as material collected, and therefore cannot be verified.

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 testing services provided to the enrollee on February 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the long term care hospice services (code T2046) provided 
from December 1, 2019 to December 31, 2019. 
 
You asked the Plan to pay for the long term care services. You say that you were told that you must bill the 
Plan for these room and board charges. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the billed code is not valid for Medicare purposes and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare 
purposes and is not payable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the long term care services have not been met. Therefore, we decided that the Plan does not have to 
pay for the long term care hospice services (code T2046) provided from December 1, 2019 to December 31, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you 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 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 you are currently undergoing treatment at an acute care hospital for respiratory 
failure in the setting of acute-on-chronic renal failure. You were intubated/ventilated and subsequently received 
a tracheotomy. You are tolerating ventilator weaning. There is no evidence that you require services that are 
not currently available where you are currently receiving 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 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: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for the x-ray. We decided that the Plan does not have to 
waive the coinsurance for the surgery, the fluoroscopy, and the Part B drugs.  
 
 
You asked the Plan to waive the coinsurance for the surgery, the fluoroscopy, the Part B drugs and the x-ray. 
You say that you do not feel that the Plan covered 80% of the cost. The Plan says that you have been charged 
the correct cost sharing amount. 
 
We decided that the Plan has to reduce the coinsurance for the x-ray.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles, and coinsurance). The records show that you were charged a 20% 
coinsurance for the x-ray. 
 
The Plan says that you must pay $59 for the x-ray. Based on the plan contract, however, you cannot be asked to 
pay more than a $50 copayment for the x-ray. Therefore, we decided that the Plan has to reduce the cost for 
service from a coinsurance amount of $59 to a $50 copayment.  
 
We also decided that the Plan does not have to waive the coinsurance for the surgery, the fluoroscopy, 
and the Part B drugs. 
 
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% 
coinsurance for the surgery, 20% coinsurance for the fluoroscopy, 20% coinsurance for the Part B drugs. 
Therefore, we decided that the Plan does not have to waive the coinsurance for the surgery, the fluoroscopy, 
and the Part B drugs. See chart below. 
 
Date of Service Service Allowed Amount Coinsurance/Copayment Member 
Liability 
March 3, 2020 Part B drugs $788.71 20% $157.73 
March 3, 2020 Fluoroscopy $875 20% $175 
March 3, 2020 Surgery $27,541.49 20% $5,508.29 
March 3, 2020 X-ray $295 $50 $50 
Total    $5,891.02 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT colonography screening. 
 
You asked the Plan to pre-approve the screening. You say that the colon is outside of the body, and this test is 
really needed. The Plan denied your request. The Plan says there was poor preparation with the previous 
colonoscopy attempt in March 2020. 
 
The Plan must follow Medicare rules. Medicare rules say that CT colonography is not a covered service. 
 
The requested test is statutorily not covered. Based on this information, we decided that Medicare rules for 
coverage of the screening have not been met. Therefore, we decided that the Plan does not have to pre-approve 
CT colonography screening.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary. The Plan denied your 
request. The Plan says that they did not receive documentation supporting the medical necessity for a step 
therapy exception. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary for the enrollee in this case. The patient has previously tried 
Remicade but there is no documentation of trial and failure of Stelara. There is no indication that Stelara would 
likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the 
enrollee's condition does not meet step therapy criteria for Entyvio. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.