Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four (4) additional occupational visits (97530). 
 
You asked the Plan to pre-approve additional OT visits. You say that the additional visits are necessary. The 
Plan denied your request. The Plan says the enrollee was approved for eight occupational therapy visits to help 
improve his coordination and improve his ability to complete daily activities. The remaining 4 visits are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 additional OT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy generally is not accepted as specific 
and effective therapy for the enrollees condition beyond what was approved by the health plan. The enrollee 
has had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist.  The requested services are not part 
of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 
required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent 
or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional OT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve four (4) additional occupational visits (97530).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of amniotic membrane on the ocular 
surface. 
 
You asked the Plan to pre-approve the placement of amniotic membrane on the ocular surface. You say that 
several treatments have been tried to resolve the enrollee's condition and all have failed. You say that the 
placement of Prokera helps with scarring, blood vessel formation, and inflammation. You say that it helps 
prevent conjunctival closure or adhesions. The Plan denied your request. The Plan says placement of amniotic 
membrane on the ocular surface without sutures is not a standard of care for keratoconjunctivitis sicca yet. The 
Plan says that the requested procedure is 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 the placement of amniotic membrane 
on the ocular surface. Our reviewer says that the placement of amniotic membrane on the ocular surface is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a 
diagnosis of dry eye syndrome/keratoconjunctivitis sicca. Per exam October 24, 2022, the enrollee states vision 
is blurry, and wants new glasses; "no burning, no irritation, no foreign body sensation."  The records show that the enrollee is not taking eye drops as indicated.  "No dryness, no discomfort."  Visual acuity is 20/60 OD and 
20/30 OS.  On exam, cornea has 3+ punctate keratopathy of the right eye.  Assessment is dry eye syndrome, 
prior placement of Prokera April 11, 2022, with improvement but now regressed on exam.  Other treatment is 
autologous serum drops. The enrollee is noted on the last clinical exam to not using the eye drops as instructed.  
The enrollee has not failed medical therapy as they are not using the eye drops for dry eyes as instructed. The 
documentation does not support that placement of amniotic membrane on the ocular surface without sutures is 
medically reasonable and necessary for the enrollee in this case.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the placement of amniotic membrane on the ocular surface have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the placement of amniotic membrane on the 
ocular surface.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA Molecular Signature test (81479) provided on 
March 14, 2022. 
 
You asked the Plan to pay for the PrismRA Molecular Signature test. You say that this test was medically 
necessary. The Plan denied your request. The Plan says services considered to be experimental or 
investigational are excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the PrismRA test is not FDA approved. Based 
on this information, we decided that Medicare rules for coverage of the PrismRA Molecular Signature test have 
not been met. Therefore, we decided that the Plan does not have to pay for the PrismRA Molecular Signature 
test (81479) provided on March 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for multiple computed tomography (CT) scans 
provided on July 11, 2022. 
 
You asked the Plan to waive the copayment for multiple computed tomography (CT) scans. You say that you 
have been charged multiple $50 copayments and you aren't sure why. 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 $50 
copayment for Physician/Practitioner services, including doctor's office visits ($50 x 2 CT scans = $100 total 
copayment).  
 
You have been asked to pay a $100 total copayment for multiple computed tomography (CT) scans. This 
item/service falls within the Physician/Practitioner services, including doctor's office 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 multiple computed tomography 
(CT) scans provided on July 11, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an MRI provided on June 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an MRI. You say that the service was medically necessary, and you are 
appealing with supporting documentation. The Plan denied your request. The Plan says the enrollee must 
receive care from a network provider 
 
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 an MRI provided on June 9, 2022, by an out-of-
network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on June 1, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility care. You say that the physician provided medically 
necessary services, and you are requesting reconsideration. The Plan denied your request. The Plan says the 
enrollee must receive care from a network provider. 
 
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 skilled nursing facility care provided on June 1, 
2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 14, 
2022. 
 
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 January 14, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services provided to the enrollee on May 
19, 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 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 99152 is "Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older." 
 
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 not supported by the medical records. Our reviewer found that the documentation does not 
specify the doses or timing of the sedation used.  There is no intra-procedure vital signs. The documentation 
does not meet criteria and therefore, the coding is not supported. 
 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 moderate sedation services provided to the enrollee on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Barostim Neo system. 
 
You asked the Plan to pre-approve a Barostim Neo system. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have 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 a Barostim Neo system. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains an absence of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of Barostim Neo in patient management. As a result, at this time 
the Barostim Neo system would not be considered medically reasonable and necessary in this enrollees 
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 a Barostim Neo system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Barostim Neo system.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the Vitamin D test you received on May 6, 2022. 
 
You asked the Plan to hold you harmless for the Vitamin D test. You say that this test was ordered by your 
doctor so you are not sure why this claim was denied. The Plan denied your request. The Plan says that the 
provider did not bill this service with an appropriate diagnosis code. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the Vitamin D test by a contract provider. The file does not show that the Plan provided 
prior notice that the Vitamin D test would not be covered. As a network provider, the provider of this test 
should know what services are covered and which ones are not.  In addition, the provider is obligated to bill for 
services correctly.  This network provider's failure to bill correctly should not be your financial obligation. 
 
We tried on multiple occasions to confirm with the Plan that you were not being held financially responsible 
for this claim.  We sent them Requests for Information both via email and via fax and the Plan failed to respond 
to any of them.  As a result, we can only assume that at this point you are being billed for this service.  Under 
Medicare rules, you cannot be responsible for a service that a network provider rendered to you unless the Plan 
told you beforehand that it would not be covered.  That is not the case here, which is why the Plan cannot hold 
you financially liable for this service. Therefore, we decided that the Plan has to hold you harmless for the 
Vitamin D test you received on May 6, 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: 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 
March 25, 2022. 
 
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 March 25, 2022.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
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 that you do not require the intensity of services provided at an IRF. Your care needs 
can be met 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on April 4, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for drug testing. You say that you would like to request reconsideration of the denied 
claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received 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 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 drug testing provided on April 4, 2022, by an out-
of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care at an out-of-network provider. 
 
You asked the Plan to pre-approve SNF. You say that you would like reconsideration because the services are 
medically necessary The Plan denied your request. The Plan says there is an in network SNF near you that can 
provide the care and services you need. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
SNF care at an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lab culture provided on June 29, 2022. 
 
You asked the Plan to waive the copayment for a lab culture. You say that this should be a $0 copayment as 
you were seen by your primary care provider that day, who ordered this test. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $8.07 which is less than the $10 copayment for a lab 
culture. 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 lab culture provided on June 
29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing (G0482) provided on March 28, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory testing. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 laboratory testing (G0482) provided on March 28, 
2022, by an out-of-network (OON) provider.