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

 
We decided that the Plan does not have to pay for hereditary cardiovascular panel testing provided on  
March 17, 2021. You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies 
coverage for all cardiovascular risk assessment tests - except the basic lipid panel - for suspected or 
documented cardiovascular disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover 
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary 
cardiovascular panel testing provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided to the enrollee from December 12, 
2020, to December 16, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid as billed. The Plan denied 
your request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.  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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer 
found the enrollee was diagnosed with unspecified severe protein-calorie malnutrition during a hospitalization 
for urinary tract infection due to self-catheterization. He was placed on a regular diet in the hospital. He had 8% 
body weight loss in the prior 2 months and albumin was 1.9 on admission with generalized weakness and lack 
of coordination. Records state the low albumin was related to liver disease and hyponatremia. He was 
tolerating 50%k of his food on admission. The records did not show signs of this diagnosis such as very low 
albumin/prealbumin related to diet, muscle wasting, or low weight. Therefore, the documentation does not 
support the DRG of 698 originally submitted. We looked at this physician's review, the file, and Medicare 
rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. 
Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from 
December 12, 2020, to December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says this is statutorily non 
covered by Medicare. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
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, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. In addition, since the related base device is noncovered, 
the accessory coded as E0673 will be denied. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device (E0675).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for inpatient hospital services rendered on 
September 29, 2020, to October 1, 2020. 
 
You asked the Plan to waive the copayments for inpatient hospital services. You say that if you had known of 
the post open wound issues on your lower back prior to the procedure you would have taken a different route.  
 You also say that you have had pain and suffering for four months after your operation due to negligence and 
incompetence from the surgeon's office, which was not necessary. You also say that you should not be subject 
to any further financial harm. The Plan denied your request. The Plan says you were 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 $200 
copayment per day for days 1 ? 5 for Inpatient Hospital Care.  
 
You have been asked to pay a $400 copayment for inpatient hospital services ($200 copayment x 2 days = 
$400). 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 inpatient hospital services rendered on 
September 29, 2020, to October 1, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the ultrasound-guided breast biopsy and 
the diagnostic mammogram you had on April 20, 2021. 
 
You asked the Plan to waive the cost sharing for the biopsy and the diagnostic mammogram. You say that you 
were in an office to get a mammogram and were then told to get an ultrasound.  You stated that you were not in 
a hospital. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 
copayment for outpatient surgery and 5% coinsurance for diagnostic mammograms.  
 You have been asked to pay a $250 copayment for the biopsy and 5% coinsurance for the diagnostic 
mammogram. Biopsies are considered surgical services, and the provider from whom you received this surgery 
is considered an outpatient hospital facility. In addition, you were appropriately charged the 5% coinsurance for 
the diagnostic mammogram. 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 cost sharing for the ultrasound-guided 
breast biopsy and the diagnostic mammogram you had on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Nivolumab and Ipilimumab for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence that these drugs are safe and effective for esophageal cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drugs. Our reviewer says that the 
requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of 
ipilimumab and nivolumab is not Food and Drug Administration (FDA) approved for the treatment of 
metastatic/recurrent squamous cell esophageal cancer. This use is not supported in the National Comprehensive 
Cancer Network (NCCN) guidelines, major drug compendia, or in the medical literature. The service is not 
reasonable or medically necessary and has not been proven to be safe and effective. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Nivolumab and Ipilimumab for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided from  
January 4, 2021, to March 29, 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 you 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 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 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 
physician services provided from January 4, 2021, to March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray transportation services (R0075) provided on May 
13, 2021. 
 
You asked the Plan to pay for the X-ray transportation services. You say that you would like this claim 
reprocessed for medical necessity. The Plan denied your request. The Plan says the claim has denied correctly 
based on Medicare rules. 
 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 looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed 
with a POS code of 31. The record indicates that the member was not in a Part A covered SNF stay on the 
billed date of service. There is a more appropriate POS code for the billed services. Therefore, we decided that 
the Plan does not have to pay for the X-ray transportation services (R0075) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Coolief genicular nerve radiofrequency ablation for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this procedure is considered unproven based upon a review of the peer-reviewed 
literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/ investigational procedure that is the subject of ongoing clinical 
trials. Therefore, the request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Coolief genicular nerve radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a seat lift mechanism and equipment purchased by the 
enrollee on April 12, 2021.  
 
You asked the Plan to pay for this equipment. You say that this purchase should be covered by the Plan. The 
Plan denied your request. The Plan says the provider the equipment was purchased from is not a Medicare 
eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services, or equipment provided directly by a physician or practitioner is not a Medicare eligible 
provider. The enrollee did not have prior authorization for this equipment. This equipment was not purchased 
from a Medicare eligible provider.  Therefore, we decided that the Plan does not have to pay for a seat lift mechanism and equipment purchased by 
the enrollee on April 12, 2021 from Darvin Furniture and Mattress.
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 you need more therapy than home health or long-
term care offer. The Plan denied your request. The Plan says the denial of authorization for SNF Care is 
correct. 
 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 services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility (SNF) 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on July 9, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed for medical 
necessity. 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 office visit (99214) provided on July 9, 2021, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on May 24, 2021. 
 
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not met. 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 asked our coder to carefully review the case 
file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 
this testing. Our reviewer says that Medicare coverage criteria are not met. Our reviewer found the medical 
records do not contain documentation of definitive laboratory results for 22 or more drug classes, including 
metabolites to support the coding criteria for G0483 for the billed date of service. The medical records support 
20 drug classes only. 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided to the enrollee on May 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76642) provided on March 24, 2021. 
 You asked the Plan to pay for the ultrasound services. You say that you would like these claims reprocessed 
and approved for payment. The Plan denied your request. The Plan says no additional payment is due beyond 
what was covered due to Medically Unlikely Edit 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 76642 is 2. The MAI value for this code is 2. You billed 4 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
ultrasound services have not been met. Therefore, we decided that the Plan does not have to pay for the 
ultrasound services (76642) provided on March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiological services (procedure code 95940 and 
95822) provided to the enrollee on March 13, 2020. 
 
You asked the Plan to pay for the services. You say that the denial reason is not correct. The Plan denied your 
request. The Plan says the denied code has not met the associated Place of Service relationship criteria. 
 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 95940 is "Continuous intraoperative neurophysiology 
monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List 
separately in addition to code for primary procedure)" and the definition of code 95922 is 
"Electroencephalogram (EEG); recording in coma or sleep only."  
 
We find that the denied codes are not supported in the medical record. Specifically, the enrollee was inpatient 
at the time of service. The claim was billed with a place of service 15, which means mobile unit. It should have 
been billed with place of service 21, for inpatient hospital. 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 neurophysiological services (procedure code 95940 and 95822) provided to the enrollee on March 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the luspatercept-aamt injection and 
therapeutic injection provided on April 29, 2021. 
 
You asked the Plan to reduce the coinsurance for the luspatercept-aamt injection and therapeutic injection. You 
say that the provider gave you identical treatment as the previous hospital, but the cost was $55,264.46 every 
three weeks as opposed to $2,995.02. You say that you want to know why the difference is so high and you are 
not able to pay this bill. The Plan denied your request. The Plan says the coinsurance 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 20% of 
the total cost for other Medicare-covered Part B drugs and administration from a network provider.  
  You have been asked to pay a total of $1,602.67 for the luspatercept-aamt injection and therapeutic injection.  
 
Service Allowed Amount Coinsurance Member Liability 
Luspatercept-Aamt 
Injection 
$7,979.71 20% $1,595.94 
Therapeutic Injection $33.64 20% $6.73 
TOTAL:   $1,602.67 
 
The luspatercept-aamt injection and therapeutic injection 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 reduce the coinsurance for the luspatercept-aamt injection 
and therapeutic injection provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tenotomy, percutaneous, Achilles tendon (separate 
procedure) (27606) Tenotomy, percutaneous, toe (28010) provided on July 20, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the Tenotomy service. You say that please find the attached medical records to 
support the charge denied for no authorization for redetermination. The Plan denied your request. The Plan 
says enrollee's must receive their medical services from an in-network provider with the exception being 
urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization 
before services being rendered. 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 Tenotomy, percutaneous, Achilles tendon 
(separate procedure) (27606) Tenotomy, percutaneous, toe (28010) provided on July 20, 2021 by an out-of-
network (OON) provider.