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

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
October 20, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that the EKG should be paid. You also say 
that the explanation of benefits shows your share as $14.89 but says not to bill the member. 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 $20 
copayment for non-radiological diagnostic services, including EKGs.  
 
  
You have been asked to pay the allowed amount of $14.89, which is less than the $20 copayment for an EKG. 
Your Explanation of Benefits says that you should not be billed for the remaining balance; however, you are 
responsible for your share.  An EKG 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 an electrocardiogram 
(EKG) provided on October 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network radiology services provided to the enrollee on 
March 9, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The 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 out of network radiology services provided to the 
enrollee on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene analysis (frataxin) for abnormal alleles (81284) 
provided on April 8, 2021. 
 You asked the Plan to pay for the gene analysis (frataxin) for abnormal alleles. You say that you would like 
reconsideration because CPT code 81284 describes a different procedure and technique. The Plan denied your 
request. The Plan says an edit exists between CPT codes 81284 and 81286. 
 
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 81284 
is a column II code to column I code 81286. 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 the gene analysis (frataxin) for abnormal alleles (81284) 
provided on April 8, 2021.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy, flexible; diagnostic, including collection of 
specimen(s) by brushing or washing (45378). 
 
You asked the Plan to pre-approve a colonoscopy (45378). You say that the colonoscopy is medically 
necessary. The Plan denied your request. The Plan says that the colonoscopy is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say one of the characteristics of the high risk individual is 
a personal history of adenomatous polyps. 
 
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 colonoscopy (45378). Our reviewer 
says that the requested colonoscopy is considered medically reasonable and necessary in this case. Our 
physician reviewer found the follow-up surveillance of prior adenomatous colon pathology is considered by 
Medicare as a "High Risk Screening" procedure. The LCA approves coverage of follow-up colonoscopy every 
2 years for a patient with a prior history of an adenoma.  
 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 colonoscopy (45378) have been met. Therefore, we decided that the Plan has 
to pre-approve a colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing 
(45378).  
 
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 the laboratory services rendered on July 20, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge services (procedure code 99217) 
provided to the enrollee on August 27, 2021. 
 
You asked the Plan to pay for the services. You say that the rendering provider's specialty was internal 
medicine. The Plan denied your request. The Plan says a qualifying initial or subsequent observation care 
charge was not found in the enrollee's claim history. 
 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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 
as appropriate.])." 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, for this code to be 
supported, there must also be evidence of initial observation care or subsequent observation care in the claims 
history. The provider has not sent any evidence of this. 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 observation care discharge services (procedure code 99217) provided to the enrollee on August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided August 
3, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you have attached medical records to 
prove the medical necessity. Kindly review the attached documents and process the claim towards payment. 
The Plan denied your request. The Plan says the service is not supported without required documentation. 
 
The Plan must follow Medicare rules. The rules say that if consultations are unsuccessful, document the 
patients medical chart with the date and physician notification method.  
 
We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the 
services at issue. Based on this information, we decided that Medicare rules for coverage of the psychotherapy 
services have not been met. Therefore, we decided that the Plan does not have to pay for individual 
psychotherapy services (90832) provided August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the member is not ready to go home. The Plan 
denied your request. The Plan says the services you require can safely be received in a different setting. 
 
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 daily 
skilled nursing services are not necessary. Our physician reviewer found that the patient does require skilled 
therapy services but does not require skilled therapy services on a daily basis. 
 
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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 30, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Agovy injection 225/1.5 for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this drug is on the self-administered drug list, and is excluded from coverage. 
 
 
 
 
 
 
 
 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 Agovy injection 225/1.5 for 
the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documentation received indicates a low risk condition, and that other tests may be 
more appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the 4mm fissure lymph 
node is less than 6mm, and does not need surveillance. The CT of 1/15/21 describes no suspicious nodules and 
cites the Fleischner Society criteria for guidelines. Medical necessity for CT chest surveillance has not been 
established. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the chest.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the 
current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to 
daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of 
therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no 
documented acute rehabilitation nursing needs. While the enrollee may benefit from physical therapy and 
occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays and an exam of the neck and spine due to a diagnosis 
of a disorder of the teeth provided on September 13, 2021. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says these were diagnostic services ordered for dental pain which is not 
covered by the Plan or by Medicare. 
 
Medicare does not cover dental services. The Plan only covers general preventative dental services. Diagnostic 
imaging of the neck and spine due to dental pain is not an indication covered under Medicare nor the Plan. 
Therefore, we decided that the Plan does not have to pay for x-rays and an exam of the neck and spine due to a 
diagnosis of a disorder of the teeth provided on September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that further delay to LTACH will directly 
jeopardize the enrollee's ability to fully recover and successfully regain maximum independence. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to LTACH is not medically necessary nor would it be clinically 
advantageous. Transfer to a lower level of care may be considered when treatment has completed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0652). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. 
The Plan denied your request. The Plan says the beneficiary does not have lymphedema extending onto the 
chest, trunk and/or abdomen and has not tried a basic pneumatic compression device. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on April 20, 2021 
 
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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a 
PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for 
the moderate sedation services rendered on April 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services (97814 and 97813) provided on 
October 1, 2021, through October 27, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these services were rendered by a non-
covered provider type. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the record indicates that these services were rendered 
by a licensed acupuncturist. A licensed acupuncturist is not considered a physician and the records do not show 
that these services were supervised by a physician. Therefore, we decided that the Plan does not have to pay for 
the acupuncture services (97814 and 97813) provided on October 1, 2021, through October 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Armodafinil tablet 250mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says drug coverage is limited to those covered under the medical benefit. 
 
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 Armodafinil tablet 250mg 
for the enrollee.