Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy from March 3, 2022, to 
April 20, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy from March 3, 2022, to April 20, 2022 You 
say that you were told you would only be responsible for a one-time $50 copayment. The Plan denied your 
request. The Plan says the cost share has been applied 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 per visit for in-network Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $1150 for radiation therapy from March 3, 2022, to April 20, 2022. Radiation 
therapy 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 radiation therapy from March 3, 2022, to April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 16, 2021 billed 
with multiple individual gene codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is nationally covered by 
Medicare as the tests have been approved by the Food and Drug Administration. The Plan denied your request. 
The Plan says Medicare has assigned a single panel code for the Guardant360 testing. Therefore, the denial of 
the multiple billed codes is correct. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 16, 2021 billed with multiple individual gene codes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on January 17, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that that it isn't your responsibility to obtain prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary services provided on January 17, 
2022, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a second unit of 19285 billed for date of service January 10, 
2022. 
 
You asked the Plan to pay for a second unit of 19285. You say that this service was billed appropriately and is 
supported in the record. The Plan denied your request. The Plan says only one unit of this service is payable per 
day according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 In this case, the MUE for CPT code 19285 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of a second 
unit of 19285 have not been met. Therefore, we decided that the Plan does not have to pay for a second unit of 
19285 billed for date of service January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on September 9, 2021, billed 
with multiple individual gene codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is nationally covered by 
Medicare and was medically necessary for this enrollee. The Plan denied your request. The Plan says this was 
not billed with the correct panel code for the testing provided. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
September 9, 2021, billed with multiple individual gene codes.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve the portable ventilator. You say that the ventilator is medically necessary. 
The Plan denied your request. The Plan says the enrollee's needs would be met with a BiPAP machine. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the portable ventilator. Our reviewer 
says that the portable ventilator is not medically necessary. Our physician reviewer found the documentation 
does not contain sufficient detailed information in the medical record to justify the treatment selected. The 
enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device 
is covered. 
 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
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 enrollee requires three hours of therapy a day 
with medical oversight. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information they received about the enrollee's condition; the enrollee does not meet the requirements. 
 
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician 
reviewer also found that the patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. Our physician reviewer also 
found that medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrocardiogram (ECG) to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve an electrocardiogram (ECG). You say that you would like to appeal the 
denial of the 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 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 
an electrocardiogram (ECG) to be provided by an out-of-network (OON) 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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollees conditions do not require the 
level of observation, evaluation and treatment provided by a physician in the skilled nursing facility setting. 
The enrollee does not require skilled nursing services, including wound management, administration of IV 
medication, bowel or bladder training, or tube feeding. Based on the clinical documentation provided, it 
appears that the enrollee is stable from a cardiovascular standpoint. The enrollee also does not require the level 
of intensity of skilled therapy services provided in the skilled nursing facility setting. She is currently requiring 
supervision for her transfers and mobility and the physical therapy note indicated that she was safe for 
discharge home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says 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 the enrollee is not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. The enrollees care needs can be met at a lower level. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography, of the head or brain; without 
contrast material (70450). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the 
enrollee. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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 this service. Our reviewer says that the 
requested service is not medically necessary. Our physician reviewer found that the requested scan can be part 
of a workup for cognitive memory loss. However, the laboratory values for B12, thyroid stimulating hormone 
(TSH), complete blood count (CBC), and the comprehensive metabolic panel (CMP) need to be reviewed to 
confirm that they are normal. These laboratory values were not stated in the medical records; therefore, the 
requested scan is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography, of the head or brain; without contrast material (70450).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay from February 
25, 2022, to March 2, 2022. 
 
You asked the Plan to reduce the copayment for an inpatient hospital stay from February 25, 2022, to March 2, 
2022. You say that you should only be responsible to pay for 3 days of inpatient care. The Plan denied your 
request. The Plan says the copayment has been applied 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 $300 
copayment per day, for days 1-5, of an in-network hospital stay.  
 
You have been asked to pay a $1500 copayment for an in-network hospital stay from February 25, 2022, to 
March 2, 2022. An inpatient hospital stay falls within the Inpatient Hospital Care 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 reduce the copayment for an inpatient hospital stay from February 25, 2022, to March 
2, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says that the step therapy 
criteria have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The documentation submitted by the Plan does not contain medical records. The 
documentation does not show that the Plan made an effort to obtain medical records. Without records, the 
Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pre-approve Eylea.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiofrequency ablation procedure (64636, 64635). 
 
You asked the Plan to pay for the radiofrequency ablation procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that for coverage of repeat facet joint ablation procedures, 
if there is an extended time (two years or more) since the last ablation procedure, and/or there is a question as 
to the source of the recurrent pain, then diagnostic procedures must be repeated. 
 
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 radiofrequency ablation procedure. Our 
reviewer says that this procedure is not medically necessary. Our physician reviewer found it has been more 
than 2 years since the previous facet joint ablation procedure. Diagnostic procedures must be repeated before a 
repeat ablation procedure can be considered. 
 
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 radiofrequency ablation procedure have not been met. Therefore, we 
decided that the Plan does not have to pay for a radiofrequency ablation procedure (64636, 64635).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve occupational therapy (OT) to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve OT. You say that the enrollee requires occupational therapy and is unable to 
attend an outpatient facility. The Plan denied your request. The Plan says you must use network providers for 
care and services. 
 
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 
occupational therapy (OT) to be provided by an out-of-network provider.
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 does not meet criteria. 
 
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 the medical issues do not represent a barrier to standard post hip fracture 
rehabilitation. Standard hip fracture rehabilitation does not require intensive or complex rehabilitation services 
and is not an indication for frequent physiatry oversight. Significant numbers of enrollees are able to 
rehabilitate at home. Studies of post hip fracture rehabilitation outcomes have not shown improved outcomes 
with an IRF admission. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to provided additional reimbursement for a mouth lesion removal 
performed on August 19, 2021. 
 
You asked the Plan to provided additional reimbursement for the lesion removal. You say that you were 
advised to request reimbursement from the Plan for the services. The Plan denied your request. The Plan says 
the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible which applies to certain items and services.  
 
The file shows that the Plan reprocessed the claim to apply the allowed amount to your deductible. The item or 
service you asked the Plan to provided additional reimbursement for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 
deductible which applies to certain items and services.  
 
 
 
 
 This cost sharing is a contractual obligation that had not been met at the time the lesion removal was performed 
on August 19, 2021. Therefore, we decided that the Plan does not have to provided additional reimbursement 
for a mouth lesion removal performed on August 19, 2021.