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

 
We decided that the Plan has to pre-approve occupational therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that without this therapy, the muscles won't allow the 
pulmonary therapy to work as it should with any effectiveness. The Plan denied your request. The Plan says 
that the assessment showed no significant changes or decline in neck range of motion compared to earlier in the 
year. 
 
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 the visits. Our reviewer says that the 
requested visits are medically reasonable and necessary. Our physician reviewer found that the clinical 
documentation shows that you require further intervention with a recent status change and new diagnosis of 
chronic obstructive pulmonary disease, which wasn't present on the last evaluation. Therefore, outpatient 
occupational therapy visits are medically necessary, as stated by your care team. 
 
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 visits have been met. Therefore, we decided that the Plan has to pre-approve 
occupational therapy visits.  
 
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: Favorable

 
We decided that the Plan has to pay for the FoundationOneCDx (F1CDx) testing provided on March 9, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOneCDx (F1CDx) 
testing provided on March 9, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the physical therapy 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 the visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
The requested additional visits are not medically reasonable or necessary. Our physician reviewer found that in 
this case, the documentation doesnt support that the enrollee requires additional skilled rehab services to 
provide treatment that is medically necessary. The enrollee does not require additional skilled rehab services to 
effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the enrollees condition and/or prevent deterioration.  The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The 
requested home health services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve seven home physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096). 
 
You asked the Plan to pre-approve a sacroiliac joint injection (27096). You say that the requested sacroiliac 
joint injection (27096) is medically necessary. The Plan denied your request. The Plan says the requested 
sacroiliac joint injection (27096) 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 a sacroiliac joint injection (27096). Our 
reviewer says that the requested sacroiliac joint injection (27096) is not medically necessary. Our physician 
reviewer found the physical exam documentation does not show tenderness over the sacroiliac (SI) joints. The 
records do not show positive responses to 3 provocative tests of your SI joint. These criteria of physical exam 
are required. In their absence, the request is considered 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 a sacroiliac joint injection (27096) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a sacroiliac joint injection (27096).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for days 1 to 5 of the inpatient hospital stay applied 
between November 13, 2020, to November 17, 2020. We decided that the Plan does not have to waive the 
copayment for days 1 to 5 of the inpatient hospital stay applied between November 6, 2020, to  
November 11, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
the copayment. The Plan says that the copayment applied is correct.  
 
We decided that the Plan has to waive the copayment for days 1 to 5 of an inpatient hospital stay applied 
between November 13, 2020, to November 17, 2020.  
 
The rules say that a Plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, coinsurance, and deductibles). Your contract with the Plan clearly says that you must pay 
$325 copayment per day for days 1 to 5 and $0 copayment per day for additional days for each inpatient 
hospital stay. Although the Plan claims that there were two separate inpatient stays in which you were 
transferred to a different hospital, this entire claim was billed as a single inpatient stay by a single hospital. 
Therefore, only one copayment can apply to this claim. This inpatient stay lasted 47 days, resulting in a 
copayment amount of $1,625.  
 
The Plan says that you must pay a total amount of $3,250 copayment. Based on your contract with the Plan, 
however, you cannot be asked to pay more than $1,625 for this inpatient stay. Therefore, we decided that the 
Plan has to reduce your total copayment amount from $3,250 to $1,625.  
 
We also decided that the Plan does not have to waive the copayment for days 1 to 5 of an inpatient 
hospital stay applied between November 6, 2020, to November 11, 2020. 
 
The rules say that a Plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, coinsurance, and deductibles). Your contract with the Plan clearly says that you must pay 
$325 copayment per day for days 1 to 5 and $0 copayment per day for additional days for each inpatient 
hospital stay. Here is a summary of your cost-sharing responsibility: 
 
Date of Service Number of Days Copayment Member Liability 
November 6, 2020 - November 11, 2020 5 $325/day $1625 
November 12, 2020 - December 23, 2020 42 $0/day $0 
TOTAL:   $1625 
 
Therefore, we decided that the Plan does not have to waive the copayment for days 1 to 5 of an inpatient 
hospital stay applied between November 6, 2020, to November 11, 2020. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve digital hearing aids (V5260) with the out-of-network 
provider. 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested hearing aids do not meet criteria for coverage 
as they were requested to be rendered by an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.   
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were requested to be 
rendered by an out-of-network provider. The Plan contract states that enrollees must use the Plans select 
hearing aid provider to use this benefit for hearing aids. Therefore, we decided that the Plan does not have to 
pre-approve digital hearing aids (V5260) with the out-of-network provider.
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 continued SNF care is medically necessary. The 
Plan denied your request. The Plan says the member had no participation in therapy, no predicted gains from 
therapy. The member does not meet CMS Chapter 8 guidelines for continued stay. 
 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 that you are unable to make material gains within a predictable time frame. Your 
cognitive impairment is severe and you are not responding to skilled therapy. There are no skilled nursing 
needs. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99283 billed for date of service March 22, 
2022. 
 
You asked the Plan to pay for procedure code 99283. You say that this should be paid. The Plan denied your 
request. The Plan says payment for code 99283 is bundled into payment for code 99284. 
 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 99283 
is a column II code to column I code 99284. 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 99283 billed for date of service March 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on February 11, 2022, and 
March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel that this should be covered. The Plan 
denied your request. The Plan says the provider has refused to submit a medical claim for these services. As 
such, no payment can be made. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
February 11, 2022, and March 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs provided on April 28, 
2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy drugs. You say that this service should have 
been paid in full. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for chemotherapy drugs. The allowed amount of the claim is $1,508.16, resulting in a coinsurance 
amount of $301.63 ($1,508.16 x 20%). 
 
You have been asked to pay $301.63 for chemotherapy drugs. Chemotherapy drugs fall within the Medicare 
Part B Prescription Drugs 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 coinsurance for 
chemotherapy drugs provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the dialysis services provided from 
January 3, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayments for the dialysis services. You say that you did not have to pay for 
your dialysis treatments in 2021. 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 $30 
copayment for outpatient dialysis services until you reach the out-of-pocket maximum.  
 
You have been asked to pay a $750 copayment for outpatient dialysis services ($30 copay x 25 treatments = 
$750). The dialysis services fall within the Services to Treat Kidney Disease 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 copayments for the dialysis services provided 
from January 3, 2022, to February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (multianalyte assay with algorithmic 
analysis) provided to the enrollee on March 24, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be 
covered. 
 
The documentation submitted did not include a physician order/lab requisition. It is not clear that the 
dermatologist ordered this testing. 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 laboratory services 
(multianalyte assay with algorithmic analysis) provided to the enrollee on March 24, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication administration services provided during the 
emergency department (ED) visit on March 27, 2022, billed with codes 96361, 96367, 96374, and 96375. 
 
You asked the Plan to pay for the services described by the codes at issue. You say that payment should be 
made for all billed codes. The Plan denied your request. The Plan says the denied codes are not payable in the 
facility setting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes billed in this case have a Pro/Tech flag of 5. This means that payment may not be 
made by carriers for these services when they are provided to hospital inpatients or patients in a hospital 
outpatient department. The file shows that the enrollee was a hospital outpatient at the time the services were 
rendered. Based on this information, we decided that Medicare rules for coverage of the services described by 
the codes at issue have not been met. Therefore, we decided that the Plan does not have to pay for the medication administration services provided during the emergency department (ED) visit on March 27, 2022, 
billed with codes 96361, 96367, 96374, and 96375.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on February 10, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not 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 provider in this case is not a network provider with the Plan. 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 medical services provided on February 10, 2022, by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 81161, 81286, 81413, 
81414, 81442 and 81479 provided October 22, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the lab does not require active medical/state 
license and your lab is operating within Texas. The Plan denied your request. The Plan says unable to verify 
providers license. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 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 the laboratory services coded as 
81161, 81286, 81413, 81414, 81442 and 81479 provided October 22, 2021. have been met. The Plan made 
multiple attempts to obtain supporting medical records from the provider without success. Therefore, we 
decided that the Plan does not have to pay for the laboratory services coded as 81161, 81286, 81413, 81414, 
81442 and 81479 provided October 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the health plan has no contractual obligation to cover additional physical therapy 
services that are not reasonable or 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 for the additional visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
The requested additional visits are not medically reasonable or necessary. Our physician reviewer found that a 
physical therapy progress noted dated 7/19/2022 indicated that your lumbar spine and hip range of motion have 
remained essentially the same. Your motor strength has also remained for the most the same. There is a lack of 
documentation indicating a significant improvement in your function and mobility with therapy. Therefore, the 
additional physical therapy cannot be considered 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten additional physical therapy visits.