Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the 
current acute care hospital can provide care. 
 
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 physician 
reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. The Plan has approved ongoing care in the current acute care 
setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 
basis. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on April 6, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on April 6, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date of service 
February 28, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service was medically necessary. The Plan denied 
your request. The Plan says this service is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for validity testing billed with code 83789 for date of service February 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 9, 2021, to April 26, 2021. 
 
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 has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate 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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the documentation does not 
support that the enrollee in this case received parenteral IV/feeding while in the hospital. The History & 
Physical documents obesity, with current BMI = 36. "Encouraged on beneficial effects of weight loss. The 
patient will follow up with his primary care physician for weight loss management and lifestyle modification." 
The clinical records do not support a diagnosis of morbid obesity due to excess calories. The Observation 
Detail List Report documents "Weight stable". Under the heading 'Nutritional Considerations', 2 or more selections are not checked. Consequently, the enrollee is not considered at risk for malnutrition. 
 
We looked at this coder'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 skilled nursing facility (SNF) services provided to the enrollee from April 9, 2021, to April 26, 
2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a non-emergency transportation provided 
on May 4, 2022. 
 
You asked the Plan to reduce the copayment for ambulance services. You say that the copayment should 
reduce to $40 copayment as that is what you had if the hospital had transported you. The Plan denied your 
request. The Plan says this cost sharing was charged 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 $125 
copayment for ambulance services.  
 
You have been asked to pay $125 copayment for ambulance services. This item/service falls within the 
ambulance services 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 a non-emergency 
transportation provided on May 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for an X-Ray, specialist office visit, and 
wrist/hand/finger orthosis provided on June 14, 2022. 
 
You asked the Plan to waive the cost-sharing for X-Ray, specialist visit, and orthosis. You say that this cost-
sharing was not mentioned to you, and you feel misled. The Plan denied your request. The Plan says this cost 
sharing was charged 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 $5 
copayment per day for X-Ray, $25 copayment for each specialist office visit, and 10% coinsurance for each 
orthotic item. The allowed amount of the wrist/hand/finger orthosis is $222.97, resulting in a coinsurance 
amount of $22.30. Therefore, your total cost-sharing amount is $52.30 ($5 copayment + $25 copayment + 
$22.30 coinsurance = $52.30). 
 
You have been asked to pay $5 copayment per day for X-Ray, $25 copayment for each specialist office visit, 
and 10% coinsurance for each orthotic item. These items/services fall within the "outpatient diagnostic tests 
and therapeutic services and supplies", "physician/practitioner services, including doctor's office visits", and 
"prosthetic devices and related supplies" benefit categories. 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 an X-Ray, specialist office visit, and wrist/hand/finger orthosis provided on June 14, 2022.  
 
Your complaint about feeling misled about this cost-sharing is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on July 22, 2021 billed with 
codes 81407 and 81408. 
 
You asked the Plan to pay for the genetic testing billed. You say that this should be paid for. The Plan denied 
your request. The Plan says if one laboratory procedure evaluates multiple genes using a next generation 
sequencing 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 CPT code. 
 
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 
July 22, 2021 billed with codes 81407 and 81408.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for physical therapy (PT) services provided from June 9, 
2022, to June 14, 2022. 
 
You asked the Plan to waive the coinsurance for the PT services. You say that you are being billed the 
coinsurance that should be paid by Medicaid. The Plan denied your request. The Plan says that this cost sharing 
was charged 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 does not say in clear and accurate terms 
how much you should expect to pay for outpatient rehabilitation services.  
 
We looked at your contract with the Plan. We did not see where the contract specifically says enrollees must 
pay a 20% coinsurance for outpatient rehabilitation services. The Plan contract does not clearly say when the 
coinsurance should be 0% and when it should be 20%. This means that the Plan did not follow Medicare rules 
for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for 
physical therapy (PT) services provided from June 9, 2022, to June 14, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 25605) provided to the 
enrollee on July 27, 2021. 
 
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 records do not support the services billed. 
 
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 25605 is "Closed treatment of distal radial fracture (eg, 
Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when 
performed; with manipulation." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the closed treatment of the 
fracture did not include fracture manipulation, based on fracture type and documentation provided. Therefore, 
the records do not support that CPT 25605 was actually rendered in this case.   
We looked at this coder'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 surgical services (procedure code 25605) provided to the enrollee on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Linzess capsules. 
 
You asked the Plan to pre-approve Linzess. You say that Linzess is medically necessary. The Plan denied your 
request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Linzess capsules.  
 
Benefits for Linzess may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered on August 11, 2021, to 
August 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services 
were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy rendered on August 11, 2021, to August 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a colonoscopy provided on April 25, 2022. 
 
You asked the Plan to waive the cost for a colonoscopy. You say that this was supposed to be a routine 
procedure and should not have a cost share. The Plan denied your request. The Plan says this cost sharing was 
charged 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 $45 
copayment for a specialist visit, and a 20% coinsurance for outpatient surgery for physician/practitioner 
services, including doctor office visits, and outpatient surgery, including services provided at an ambulatory 
surgical center. The allowed amount of this item or service was $742.06, resulting in a coinsurance of $148.41 
($742.06 x 20% = $148.41) + $45 copayment for the provider. 
 
You have been asked to pay a $45 copayment for a specialist visit, and a $148.41 coinsurance for outpatient 
surgery for a colonoscopy ($45 + $148.41 = $193.41).  This item/service falls within the physician/practitioner services, including doctor office visits, and outpatient 
surgery, including services provided at an ambulatory surgical center 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 cost for a colonoscopy provided on April 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and 
ground mileage (A0425) provided on November 23, 2021. 
 
You asked the Plan to pay for the non-emergent ambulance transportation and ground mileage. You say that 
the services provided were medically necessary, and Medicare is responsible for this claim The Plan denied 
your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the enrollees terminal condition. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and 
ground mileage (A0425) provided on November 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided on March 
27, 2022, to April 08, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says this cost sharing was charged 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 2% 
coinsurance for $24.98. 
 
You have been asked to pay 2% coinsurance for inpatient hospital care. This item/service falls within the 
$24.98 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 inpatient hospital care provided 
on March 27, 2022, to April 08, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ankle surgery provided on May 11, 2022. 
 
You asked the Plan to waive the coinsurance for ankle surgery. You say that you cannot afford this The Plan 
denied your request. The Plan says this cost sharing was charged 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% 
coinsurance for surgery services. 
 
You have been asked to pay 20% coinsurance for ankle surgery. This item/service falls within the surgery 
services 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 ankle surgery provided 
on May 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Coflex interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
insufficient evidence of efficacy. 
 
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 requested services. Our physician 
reviewer found that the Coflex device is experimental. More research is needed to show safety and efficacy. 
Therefore, the request is 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Coflex interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 29, 2022. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim re-reviewed. The Plan 
denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 29, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography rendered on March 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 95861 is not supported. 
 
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 95861 is needle electromyography; 2 extremities with or 
without related paraspinal areas. The definition of code 95870 is needle electromyography; limited study of 
muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, 
cranial nerve supplied muscles, or sphincters.  
We find that CPT codes 95861 and 95870 are not supported in the medical record. Specifically, the codes were 
not reported with a nerve conduction study. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
needle electromyography rendered on March 22, 2022.