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

 
We decided that the Plan does not have to reimburse you for the Infectious agent detection by nucleic acid 
(DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease 
[COVID-19]), amplified probe technique (87635) provided May 8, 2022 while outside of the Unites States. 
 
You asked the Plan to reimburse you for the laboratory services. You say that you were in Vancouver Canada 
and was exposed to COVID-19. You received COVID test, and it was negative. You thought that you could 
receive medical care and testing anywhere in the world and pay 20% of the bill. The Plan denied your request. 
The Plan says COVID tests are only covered outside of the United States if treatment if given at an emergency 
room or urgent care center. The testing clinic was located at the Vancouver airport. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to 
reimburse you for the Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory 
syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique 
(87635) provided May 8, 2022 while outside of the Unites States.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrocentesis, aspiration and/or injection, major joint or 
bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (CPT code 20610). 
 
You asked the Plan to pre-approve the service. You say that this enrollee clearly has traumatic arthritis and a 
documented history of such which with closer chart review would be easily identified. The Plan denied your 
request. The Plan says the enrollee's request is not medically necessary because the enrollee's records show 
they do not have osteoarthritis. 
 
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 service. Our physician reviewer 
found there is no compelling rationale presented or extenuating circumstances noted to support the medical 
necessity of this request as an exception. Therefore, the requested CPT 20610- arthrocentesis, aspiration, and/or 
injection major joint or bursa without ultrasound guidance, in this case, is not medically reasonable or 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 
subacromial bursa); without ultrasound guidance (CPT code 20610).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient mental health services rendered on March 11, 
2022. 
 
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 there is no valid primary care physician referral. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for the outpatient mental health services rendered on 
March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment 
of OSAS/OHS and thoracic restriction. The Plan denied your request. The Plan says the request for a home 
mechanical ventilator set in AVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP is not 
covered. 
 
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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a history of OSA, is 
severely obese, and has HFpEF. The enrollee was hospitalized with COVID pneumonia in July 2022, and ABG 
while acutely ill was consistent with acute-on-chronic hypercarbic respiratory failure. However, there is no 
ABG as an outpatient while stable to confirm chronic CO2 retention. The enrollee is reportedly on BiPAP at 
home for the OSA, but there is no documentation of compliance. There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease. If the enrollee does have chronic CO2 retention, may benefit 
from BiPAP titration sleep study with capnography to optimize BiPAP settings. BiPAP can provide AVAPS if 
needed. Medicare does not cover a home ventilator for this diagnosis, or 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on June 07, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that this was a follow up visit for 
stitches removal. You should not have to pay another 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 a $45 
copayment for urgently needed services. 
 
You have been asked to pay a $45 copayment for an urgent care visit. This item/service falls within the 
urgently needed 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 an urgent 
care visit provided on June 07, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have documented skilled nursing needs or documented skilled therapy 
needs. You are ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your 
care needs can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3-dimensional intensity modulated radiation therapy (3-
D IMRT). 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of IMRT for breast cancer is not 
listed as an accepted indication in the Medicare rules. The documentation does not support that the IMRT is 
reasonable and medically necessary for the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3-dimensional intensity modulated radiation therapy (3-D IMRT).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for in-network surgical services provided on 
May 9, 2022 and May 16, 2022. 
 
You asked the Plan to waive the copayment for the surgical services. You say that you were told by the 
receptionist at the facility that these services would be covered. The Plan denied your request. The Plan says 
the copayment 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 $350 
copayment for surgery services at an in-network outpatient hospital. 
 
You have been asked to pay a $350 copayment for each visit. There were two visits for surgical services, 
resulting in a total copayment amount of $700. Surgical services fall 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 in-network surgical services 
provided on May 9, 2022 and May 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute grafting. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has an abscess on the 
shoulder. The records indicate that the wound is healing with current treatment. There is insufficient literature 
to support the requested skin substitute compared to standard treatments. The skin substitute grafting is 
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 skin substitute grafting.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulation treatment. 
 
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no documentation indicating a misalignment of the spine. 
 
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 treatment. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that in this case, the record indicates that you have scoliosis. The record provided does not 
indicate the presence of subluxation by physical examination or by x-ray. The elements of the coverage criteria 
are not satisfied. The requested service is not 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 the treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve chiropractic manipulation treatment.
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 you need special care that cannot be provided at 
home. The Plan denied your request. The Plan says while you will likely benefit from ongoing therapy to 
enhance rehabilitation potential, there is no evidence that this cannot safely be done at a lower level of care. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pre-approve CGM supplies. You say that these are medically necessary. The Plan denied 
your request. The Plan says that there is no documentation that you are treated with multiple insulin injections 
daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of CGM supplies 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose 
monitor (CGM) supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided from April 6, 2022, to 
May 10, 2022 by an out-of-network provider. 
 
You asked the Plan to pay for physical therapy services. You say that you were under the impression that your 
provider obtained a prior authorization for these services. The Plan denied your request. The Plan says in most 
cases, care you receive from an out-of-network provider (a provider who is not part of our Plans network) will 
not be covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physical therapy services provided from April 6, 2022, to 
May 10, 2022 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 14, 2022 by an 
out-of-network provider. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the Plan 
has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care 
and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on February 14, 2022 by an out-of-
network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure, GeneSight 
Pychotropic test (81479) provided May 18, 2022. 
 
You asked the Plan to pay for the GeneSight Pychotropic test. You say that you request reconsideration of the 
original determination and coverage of the GeneSight Pychotropic test as medically necessary. The Plan denied 
your request. The Plan says GeneSight Psychotropic has not been shown to be useful, is not considered 
medically necessary and appropriate. It is a noncovered test by Medicare per DEX Diagnostics. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the GeneSight Pychotropic test have not been met. Therefore, we decided that the Plan does not 
have to pay for unlisted molecular pathology procedure, GeneSight Pychotropic test (81479) provided May 18, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0416 billed for date of service March 11, 
2022. 
 You asked the Plan to pay for procedure code G0416. The Plan denied your request. The Plan says this code is 
included in the skilled nursing facility payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the SNF for its Part A inpatients and are not separately payable. 
 
The records indicate that this service was provided to the enrollee while a SNF inpatient. Per the Physician Fee 
Schedule, CPT code G0416 has a Professional/Technical indicator of 1. This means that CPT code G0416 has 
both a professional and technical component. In this case, CPT code G0416 has not been billed with an 
appropriate modifier to indicate the professional component. Based on this information, we decided that 
Medicare rules for coverage of procedure code G0416 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code G0416 billed for date of service March 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Hepatitis C antibody test provided on May 26, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for Hepatitis C antibody test. You say that you would like to request reconsideration 
for payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Hepatitis C antibody test provided on May 26, 
2022, by an out-of-network (OON) provider.