Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic visit provided by an out-of-network provider 
on April 18, 2022. 
 
You asked the Plan to pay for a chiropractic visit. You say that when you called to make the appointment you 
were told the provider was in-network and it was also stated again on the date of service. The Plan denied your 
request. The Plan says the services were neither urgent nor emergent, were not approved in advance, and were 
rendered by an out-of-network provider. The Plan also states that call history records do not indicate you or the 
provider contacted the Plan prior to service to check the providers network status. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
 
 
 
 
 
 The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for a chiropractic visit provided by an out-of-network provider on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xG hereditary cancer panel provided to the 
enrollee on September 23, 2021. 
 You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says a review of the medical literature and clinical practice guidelines does not support hereditary 
cancer testing for local prostate cancer and the given family history. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee has recurrent, relapsed, refractory, metastatic, 
or advanced stage III or IV cancer. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Tempus xG hereditary cancer panel provided to the enrollee on September 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 6, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service May 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on May 9, 2022. 
 
You asked the Plan to pay for foot orthotics. You say that you are trying to keep up with an exercise 
regimentation to avoid any further heart surgery. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on May 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from 
August 9, 2021, to August 11, 2021. 
 
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 DRG was updated in this case.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 872 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITHOUT MCC). 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 that in this case, there is insufficient documentation to support a 
diagnosis of sepsis, as a clear diagnosis and plan of treatment was not documented throughout this hospital 
stay, until the discharge summary documents sepsis-resolved. The documentation supports acute bacterial 
prostatitis.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from August 9, 2021, to August 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Pigmented Lesion Assay and the TERT promotor testing 
provided to the enrollee on February 16, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the provided records do not mention if the lesion meets ABCDE criteria or the size of 
the lesion. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that documentation does not support that the coverage criteria established in LCD L38151 for pigmented 
lesion assay have been met in this case. It is not documented in the medical records that the lesion was between 
5mm and 19mm, and met one or more ABCDE criteria. It is also not documented that the skin was intact and 
did not contain a scar. The documentation does not support that the testing in this was medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Pigmented Lesion Assay and the TERT promotor testing provided to the enrollee on 
February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urologic oncology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee is established with this office. The 
Plan denied your request. The Plan says the service is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
urologic oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the upper extremity joint. 
 
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says that you have not 
completed six weeks of provider-directed treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found 
that you have left shoulder pain and positive signs of impingement on physical exam. The x-rays show severe 
degenerative changes of the acromioclavicular (AC) joint and a high riding humeral head. Your history and 
physical exam are highly suspicious for rotator cuff tear. These clinical and x-ray findings are so suggestive of 
chronic rotator cuff tear, the usual requirement of 6 weeks of physical therapy prior to approval of MRI are not 
reasonable. Therefore, the requested MRI of the left shoulder is medically reasonable and necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve 
magnetic resonance imaging (MRI) of the upper extremity joint.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services provided on March 11, 
2022. 
 
You asked the Plan to waive the copayment for the wound care. You say that you believe the coding is 
incorrect. 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 a $400 
copayment for outpatient hospital services.  
 
You have been asked to pay $150, which is less than the $400 copayment for the wound care. The wound care 
falls within the Outpatient Surgery, Including 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 wound care 
services provided on March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a wound debridement provided on April 
12, 2022. 
 
You asked the Plan to waive the copayment for a wound debridement. You say that this copayment is too high, 
and you have to have this done every other week. Currently you're having this done every week. The Plan 
denied your request. The Plan says the copayment that was applied was 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 a $200 
copayment for in-network Medicare covered outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay a $200 copayment for a wound debridement. A wound debridement falls within 
the Outpatient Hospital 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 a 
wound debridement provided on April 12, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services (procedure code 27486) provided to the enrollee on 
March 4, 2022. 
 
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 that the records do not support 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 27486 is "Revision of total knee arthroplasty, with or without allograft; 1 component." 
 
We asked our coder 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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
instability of internal right knee prosthesis and displaced oblique fracture of shaft of right femur. She 
underwent right knee revision open reduction internal fixation of distal femur periprosthetic fracture nonunion 
with placement of intramedullary nail and locking screws; removal of prior lateral plate and screws; revision of 
tibial component with thicker polyethylene tibial liner placed on 3/4/22. The procedure indicates that some 
laxity of the knee joint with some incompetence of the MCL and wearing of the poly liner medially. The poly 
liner was removed and synovial fluid was taken for culture. The fracture site was debrided and reduction with 
fixation was performed. A trial of 13mm poly was placed and with this more stabilized component, the knee 
showed no significant medial instability through the range of motion. 13mm Stryker TS poly implant was 
placed. This is a revision of one component (tibial component) of a total knee arthroplasty, due to laxity. 
Therefore, the records do support that CPT 27486- revision of total knee arthroplasty, with or without allograft, 
1 component- was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical services (procedure code 27486) provided to the enrollee on March 4, 2022.  
 
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 pay for procedure code 70450 billed for date of service August 1, 
2021. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service August 1, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says that based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that clinical documentation shows that the enrollee has multiple medical complications that require close 
monitoring on an inpatient basis. Therapy evaluations show that the enrollee does require two disciplines. 
When authorization was first submitted to the Plan, the enrollee was not able to tolerate 3 hours of therapy. 
However, the enrollee has made progress in the updated notes, thus IRF criteria has been met and is medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance on April 14, 2022. 
 
You asked the Plan to waive the copayment for ambulance. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says the cost sharing 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 a $300 
copayment for each covered, one-way ambulance trip by ground or water. Covered ambulance services include 
fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide 
care if they are furnished to a member whose medical condition is such that other means of transportation could 
endanger the persons health or if authorized by the plan. The provider billed in the amount of $950 and the 
allowed amount is $273.77. This is less than the copayment amount. Therefore, results in the total cost sharing 
amount of $273.77. 
 
 
 You have been asked to pay a $273.77 copayment, which is less than the copayment for ambulance. 
Ambulance 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 ambulance on April 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a spine x-ray provided on October 28, 2021. 
 
You asked the Plan to waive the deductible for a spine x-ray. You say that you have so many copayments 
already, you do not want to pay this one also. The Plan denied your request. The Plan says the deductible 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 $500 
deductible for certain services, including outpatient basic radiological services.  
 
You have been asked to pay a $10.97 deductible for a spine x-ray. A spine x-ray falls within the Outpatient 
Basic Radiological 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 deductible for a spine x-ray 
provided on October 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan 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 a portable ventilator. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the ventilator at issue meets Medicare criteria for medically necessary 
and reasonable for you. The requested ventilator is to be used in average volume assured pressure support 
mode with Auto-expiratory positive airway pressure (EPAP) which could be provided by bilevel positive 
airway pressure (BiPAP) with a backup rate and average volume assured pressure support. As stated in the Local Coverage Determination (L33800): Claims for ventilators used to provide continuous positive airway 
pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator.