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

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization 
imaging (78815). 
 
You asked the Plan to pre-approve a PET scan. You say that the enrollee suffers from emphysema and 
bronchiectasis. The records submitted are the most up-to-records reflecting last office visit on 10/6/2022 and 
clinical notes explaining why the enrollee needs the PET CT Scan. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria established by the Centers of Medicare and Medicaid Services (CMS). 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
emphysema and bronchiectasis. The record indicates that the enrollee recently underwent a CT scan of the 
chest that did not reveal an area of malignancy. The requested test is being used for cancer screening. The 
requested procedure is not being used for an enumerated condition for which coverage is available. The record 
provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the 
requested service. A PET that was done for screening so not covered by the NCD, but also 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 a PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography 
(CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 29, 2021. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 12, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit under your 
contractual policy or by Medicare for your condition. 
 
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 pre-approve foot orthotics (L3020).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271). 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration 
of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of the requested service. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   
We reviewed the file and the Medicare rules. Based on this information, we find that the enrollee does not meet 
Medicare criteria for coverage of this service. Specifically, the rules say that Medicare covers one annual 
LDCT scan for lung cancer screening for enrollees who are between 55 and 77 years of age. Therefore, we 
decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening (71271).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard Liquid 10% vial. 
 
You asked the Plan to pre-approve Gammagard Liquid 10% vial. 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 Medicare may pay for unlabeled uses for FDA-
approved 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 pre-approve Gammagard Liquid 10% vial. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the 
record indicates that the enrollee has a diagnosis of cold agglutinin hemolytic anemia. The Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard Liquid 10% vial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Gammagard Liquid 10% vial.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 9, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve five additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve five additional non-emergency transportation trips. You say that you are 
requesting an additional five trips. The Plan denied your request. The Plan says the service is not covered 
beyond the 60 allotted one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve five additional non-emergency transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and 
should be paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-spinal bone growth (osteogenesis) stimulator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered when 
specific criteria are met. 
 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that you have a 
fracture of the shin bone (right proximal tibia) that occurred on May 8, 2022. The x-ray on September 1, 2022 
showed a fracture callus. The records do not document a minimum of two sets of x-rays obtained prior to 
treatment with a bone growth stimulator, taken a minimum of 90 days apart. The criteria for coverage are not 
met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-spinal bone growth (osteogenesis) stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mobile cardiovascular telemetry monitor (93228, 
93229). 
 
You asked the Plan to pre-approve the mobile cardiovascular telemetry monitor. You say that this device is 
medically necessary. The Plan denied your request. The Plan says 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 the mobile cardiovascular telemetry 
monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found there was insufficient documentation to support the medical 
necessity for a mobile cardiovascular telemetry monitor in this patients clinical management. 
 
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 mobile cardiovascular telemetry monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a mobile cardiovascular telemetry monitor (93228, 93229).
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. You say that the enrollee would benefit from the IRF as they have 
some anxiety about going home. The Plan denied your request. The Plan says IRF admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The enrollee can 
receive further services at a lower 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dayvigo 10MG tablet. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Dayvigo is on the self-administered drug list and is excluded from coverage under 
Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dayvigo 10MG tablet.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient rehabilitation service provided 
on May 31, 2022. 
 
You asked the Plan to waive the copayment for physical therapy visit. You say that you were informed by a 
Plan representative that you are eligible for 20 physical therapy visits at no cost or copayment. The Plan denied 
your request. The Plan says this cost sharing was charged 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 $35 
copayment for Medicare-covered physical therapy in-person visits.  
 
You have been asked to pay $35 copayment for physical therapy visit. This item/service falls within the 
Medicare-covered physical therapy in-person visits 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 outpatient rehabilitation service provided on May 31, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on February 8, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you were not informed of the 
copayment prior to scan. The Plan denied your request. The Plan says this cost sharing was charged 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 $150 
copayment for advanced radiology services (CT, MRI, MRA, and SPECT scans).  
 
You have been asked to pay $136.90, which is less than the standard $150 copayment for a CT scan. This 
item/service 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 a CT scan provided on February 8, 2022.  
 Your complaint about not being informed of the copayment prior to scan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic procedure provided on 
February 16, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic procedure. You say that you do not agree with the 
copayment applied to the claim for date of service February 16, 2022. The Plan denied your request. The Plan 
says this cost sharing was charged 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 $25 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $25 copayment for a diagnostic procedure. This item/service falls within the 
outpatient diagnostic tests 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 
diagnostic procedure provided on February 16, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a pulmonary function test provided on 
June 22, 2022. 
 
You asked the Plan to reduce the copayment for a pulmonary function test. You say that the copayment should 
be $30 for the visit, rather than the $40 copayment charged. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $40 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $40 copayment for a pulmonary function test. This item/service falls within the 
outpatient 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 reduce the copayment for a 
pulmonary function test provided on June 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 22, 2021, at the 
Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
diagnosis code billed is supported in the medical records. The Plan denied your request. The Plan says the 
documentation does not support that the services were billed with the appropriate diagnosis code. 
 
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 diagnosis code, I50.33, defined as Acute on chronic 
diastolic (congestive) heart failure. 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 inpatient 
hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the 
diagnosis billed. Our physician reviewer found that the Plan determined that this was an elective admission for 
a scheduled procedure. The consult note by the provider was dated 19 days prior to the admission and noted no 
physical exam was performed due to social distancing. New York Heart Association class II congestive heart 
failure noted. The anesthesia records, member questionnaire, and discharge summary do not support the 
member was experiencing an acute episode at the time of the elective admission. The discharge note indicates 
the member was admitted directly to the operating room for the procedure, tolerated it well, and was discharged 
home the next day. There was no documentation found in the submitted records to indicate concern for or 
treatment of acute congestive heart failure symptoms. The review has determined that there was no evidence 
that the member was experiencing acute episode at the time of elective admission as the services were 
originally billed. 
 
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 on June 22, 2021, at the Diagnosis Related Group (DRG) originally 
billed.