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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from December 
14, 2021, through December 31, 2021. 
 You asked the Plan to pay for SNF care. You say that you would like this claim reprocessed for medical 
necessity. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 pay for SNF care. Our reviewer says that the 
requested SNF care is not medically reasonable and necessary. Our physician reviewer found the beneficiary is 
a 79-year-old female with respiratory failure, uremia, volume overload and metabolic encephalopathy. There 
are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In conclusion, 
this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled 
nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from December 14, 2021, through December 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
brain stem provided on February 2, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not aware of the high 
copayment at the time of service. 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 $325 
copayment for each diagnostic radiology service, including MRI's.  
 
You have been asked to pay $295.27, which is less than the $325 copayment for the MRI. The MRI 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 magnetic resonance imaging (MRI) of the brain stem provided on 
February 2, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan/Derivative Euflexxa injections per dose 
(CPT code J7323). 
 
You asked the Plan to pre-approve the medication. You say that this enrollee with unilateral primary 
osteoarthritis of right knee and the enrollee has a history of failure with Synvisc. The Plan denied your request. 
The Plan says the information they got from the enrollee's doctor says the enrollee has only tried Synvisc. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating 
that the plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hyaluronan/Derivative Euflexxa injections per dose (CPT code J7323).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on April 23, 
2021. 
 
You asked the Plan to waive the copayment for the lab services. 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 per visit for laboratory tests, non-radiological diagnostic tests, flat film X-rays, and ultrasounds.  
 
The file shows that the Plan reprocessed the claim to reduce the copayment amount to $20. You have been 
asked to pay a $20 copayment for the lab services. The lab services fall 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 laboratory services provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a total hip arthroplasty performed on 
February 11, 2022. 
 
You asked the Plan to waive the copayment for the hip arthroplasty. You say that you thought hip surgery 
would be fully covered. 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 $350 
copayment per visit for surgery or services provided at an outpatient hospital facility.  
 
You have been asked to pay a $350 copayment for the hip arthroplasty. The hip arthroplasty falls within the 
Outpatient Surgery, Including Service Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a total hip arthroplasty 
performed on February 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on October 4, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for 
these services rendered by an OON 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 the medical services provided on October 4, 2021 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 22, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
and approved for payment. The Plan denied your request. The Plan says this testing service is statutorily non 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on December 
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you did not have a good experience with the 
in-network provider. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the office visit in this appeal. We found no exception that would require the Plan to 
pre-approve the office visit. The records provided for review do not show that the office visit is urgent or 
emergent. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by 
an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at 
the current hospital. 
 
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 patient appears to be improving with current treatment and should only require short-
term additional acute care services that can safely be administered at the current facility until more stable and 
appropriate for a lower level of care. The patient does not require services at the LTACH that are not already 
available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a sensor (K0553) for a continuous glucose monitor (CGM) 
provided on January 20, 2022. 
 
You asked the Plan to pay for a CGM sensor. You say that the requested item was a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The available medical records do not discuss the item at issue. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a sensor (K0553) for a continuous glucose monitor (CGM) provided on January 
20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the 
cervical and lumbar spine provided on April 9, 2021. 
 
You asked the Plan to waive the copayment for the MRI's. You say that you were not aware of any copayments 
under this insurance plan. 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 $300 
copayment per visit for outpatient diagnostic and therapeutic services and supplies, including MRI's.  
 
You have been asked to pay a $300 copayment for the MRI's. The MRI's fall 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 magnetic resonance imaging (MRI) of the cervical and lumbar spine provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204), an eye refraction (92015) and a 
computerized ophthalmic diagnostic imaging (92134) provided on January 5, 2022. 
 
You asked the Plan to pay for an office visit, an eye refraction and an ophthalmic imaging. You say that you 
are requesting reconsideration of the denied claim and have submitted clinical notes. The Plan denied your 
request. The Plan says the claim has coding discrepancies, is not coded per Medicare guidelines, or does not 
otherwise meet standards of claim coding. 
 
Medicare rules say that providers must report services correctly. The claim submission policy requires the 
taxonomy code to be listed on the HCFA-1500 claim form for the claim to be processed and paid correctly. 
 
We looked at the file and the Plan's rules. The records show the claim was submitted without the taxonomy 
code. Specifically, claims should be submitted with the taxonomy code for proper processing and 
reimbursement. Based on this information, we decided that the Plan's rules for coverage of an office visit, an 
eye refraction and an ophthalmic imaging have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit (99204), an eye refraction (92015) and a computerized ophthalmic diagnostic imaging 
(92134) provided on January 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular advancement device (MAD) provided to the 
enrollee on June 28, 2021. 
 
You asked the Plan to pay for the services. You say that the oral appliance was medically necessary. The Plan 
denied your request. The Plan says the item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the MAD is considered not medically necessary because not all Medicare criteria are 
met. Criterion A states: "... in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing."  Such an evaluation, which should include a 
complete sleep history and detailed upper airway examination, is not in the medical record.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for a mandibular advancement device (MAD) provided to the enrollee on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (83789) provided on January 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this code is not eligible for payment 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Medicare rules say that specimen validity testing is not covered separately. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen.  
The services at issue in this case are for the purpose of specimen validity testing. 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 pay for the laboratory services (83789) provided on January 7, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for magnetic resonance imaging (MRI), breast; bilateral (77049) provided 
to the enrollee on January 18, 2022. 
 
You asked the Plan to pay for the MRI. You say that this is medically necessary. The Plan denied your request. 
The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the MRI. Our reviewer says that the 
requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee breast tissue 
is heterogenously dense meaning mammography is subject to a poor screening detection tool. The enrollee has 
had bilateral lumpectomy and has had serial MRI exams after MRI guided biopsy. The MRI of 1/18/22 was 
medically appropriate in light of the history and the heterogenously dense tissue on mammography. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pay for 
magnetic resonance imaging (MRI), breast; bilateral (77049) provided to the enrollee on January 18, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen. 
 
You asked the Plan to pre-approve a CT of the abdomen. 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. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a CT of the abdomen have been met. 
Specifically, medical records were not provided. Without this documentation, medical necessity is not able to 
be established. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) 
of the abdomen.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on December 22, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
for medical necessity. The Plan denied your request. The Plan says these testing services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that panels of tests that include the FANCC gene are 
non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the next generation sequence testing 
panel included testing for the FANCC gene. This means this entire panel is not covered. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing services provided on December 
22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says the enrollee's condition is not and FDA-approved 
diagnosis for Keytruda. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with metastatic soft tissue sarcoma. In this case, Keytruda is not FDA-approved for the enrollee's 
diagnosis. In addition, there is no Medicare compendia support for Keytruda as prescribed for the enrollee's 
diagnosis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.