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

 
We decided that the Plan does not have to pay for the lab services provided on April 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed with the incorrect date of service. 
 
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 payment CPT code 81542 is not supported in the medical record. Specifically, the claim must be 
billed with the date the specimen was collected. The records show that the specimen was collected on March 2, 
2022. As such, the claim was billed with the incorrect date of service. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for the lab services provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature indicates that this service is considered 
experimental and investigational as it is not identified as widely used and generally accepted for the proposed 
use 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this device is experimental. More research is needed. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 2, 2022. 
 
You asked the Plan to pay for F1CDx testing. You say that this is an FDA-approved test provided for an FDA-
approved indication. The Plan denied your request. The Plan says this test was not billed in accordance with 
Medicare rules, as the required DEX Z-Code is missing from this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that to report a Molecular Diagnostic Test service in the state where this test was provided, the 
appropriate CPT code must be selected with one unit of service along with the appropriate DEX Z-Code 
identifier. 
 
We looked at the file and Medicare rules. This claim was not billed with the necessary DEX Z-Code. Based on 
this information, we decided that Medicare rules for coverage of F1CDx testing have not been met. Therefore, 
we decided that the Plan does not have to pay for FoundationOne CDx (F1CDx) (0037U) testing provided on 
March 2, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy. 
 
You asked the Plan to pre-approve a colonoscopy. You say that your discharge instructions from 2004 indicate 
you should have a colonoscopy performed every five years. You also say that this should be covered. The Plan 
denied your request. The Plan says that the requested services is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a colonoscopy. Our reviewer says that 
the requested colonoscopy is considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates your provider has advised 5-year colonoscopy recalls 
based on your medical history. The reviewer found that you meet the Medicare policy booklet criteria for "at 
high risk" for colon cancer. Therefore, the reviewer found that you meet the requirement of having a 5-year 
colonoscopy. 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy.  
 
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 pay for the home health services provided to the enrollee from 
August 16, 2021, to September 14, 2021. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, The RAP 
claim for services was not submitted until October 12, 2021. The documentation does not support that a RAP 
was submitted within the five day requirement. Therefore, we decided that the Plan does not have to pay for the 
home health services provided to the enrollee from August 16, 2021, to September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Manual Test Precision GU (prostate cancer genetic 
testing). 
 
You asked the Plan to pre-approve prostate cancer genetic testing. You say that this testing is medically 
necessary. The Plan denied your request. The Plan says this test cannot be found medically necessary, as there 
is no documentation in the medical record to indicate how this testing will impact any evaluation or treatment 
management for this enrollee. 
 
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 prostate cancer genetic testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation of how this testing will impact any evaluation or 
treatment management for this enrollee that has not required any recent treatment. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prostate cancer genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Manual Test Precision GU (prostate cancer genetic testing).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pulsed/coolief RFA to the lumbar spine (CPT) code(s): 
64635 and 64636). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says non-thermal modalities for facet joint denervation including chemical, low-grade 
thermal energy (less than 80 degrees Celsius), pulsed, laser, and cryoablation are considered not 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 services. Our physician reviewer 
found the review has determined that the medical records provided do not meet the requirements listed in the 
LCD for Medicare coverage. 
 
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 pulsed/coolief RFA to the lumbar spine (CPT) code(s): 64635 and 64636).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says documentation was not 
provided showing the enrollee has received treatment with Reclast in the past, or has a medical reason for not 
being able to use it. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia is 
not reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of 
Zoledronic Acid (Reclast) before they will approve the requested drug. In this case, the enrollee has not tried 
and failed the required drug. Our reviewer also found that there is no documentation provided indicating that 
the Plans required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 1, 2021, to December 3, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that Medicare Part A states 
it will pay 100% for hospitalization, and the $945 was part of the enrollee's hospitalization costs. You also say 
that this should be paid as part of the enrollee's Medicare Part A coverage. The Plan denied your request. The 
Plan says the copayment amount the enrollee has been charged is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $315 copay per day for days 1 to 7, a $0 copay per day for days 8 to 90, and a $0 copay for 
additional days for Inpatient hospital care.  
 
 
 The enrollee has been asked to pay a $315 copay per day for days 1 to 7. The inpatient hospital stay falls within 
the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital stay provided from December 1, 2021, to December 3, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the surgical services (11406 and 12032) provided on November 8, 
2021. 
 
You asked the Plan to pay for codes 11406 and 12032. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical services (codes 11406 and 12032) have been met.  Specifically, the record shows that 
the surgical services were unrelated to the diagnosis for which the initial procedure (21931) was performed. 
Therefore, we decided that the Plan has to pay for the surgical services (11406 and 12032) provided on 
November 8, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture treatment (97810). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says you have exhausted the allowable benefit for this service. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
 We looked at the case file and the Plans rules. Based on this information, we decided that the rules for 
coverage of the acupuncture treatment requested have not been met. Specifically, the record shows that you 
previously received thirty acupuncture treatments beyond Medicare coverage for the 2022 calendar year. The 
Plan benefit provides supplemental coverage of thirty acupuncture treatments per year for any condition. 
Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does 
not have to pre-approve acupuncture treatment (97810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an orthosis (L1851, L2397) provided June 3, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this equipment was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The records do not document why this brace was ordered. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for an orthosis (L1851, L2397) provided June 3, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from August 21, 2021, to August 24, 
2021, as billed with Diagnosis Related Group (DRG) 243. 
 
You asked the Plan to pay for inpatient care billed with DRG 243. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says that DRG 243 is not 
appropriate as the diagnosis of acidosis (E87.2) is not supported in the medical record. The Plan argues that 
DRG 244 is more appropriate in this case. 
 
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 inpatient care billed with DRG 243. Our 
reviewer says that the diagnosis of acidosis (E87.2) is supported in the medical records for this inpatient 
admission. Our physician reviewer found that the enrollee was admitted to the hospital with syncopy. The 
enrollee was diagnosed with bradycardia and first degree atrioventricular (AV) block. Lactic acid was noted to 
be 1.2, carbon dioxide was 18, sodium was 135, and there was an anion gap of 14-18 during the hospital stay. 
An anion gap is one indication of systemic acidosis and meets the definition of acidosis. An arterial blood gases 
(ABG) test is not needed to make this diagnosis but is useful at calculating the cause of the acidosis 
(respiratory, metabolic, drug overdose, etc.). Therefore, the records do support the billing of acidosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 243 have been met. Therefore, we decided that 
the Plan has to pay for inpatient hospital care provided from August 21, 2021, to August 24, 2021, as billed 
with Diagnosis Related Group (DRG) 243.  
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a hospital outpatient clinic visit on June 
22, 2022. 
 
You asked the Plan to reduce the copayment for a hospital outpatient clinic visit. You say that you should only 
be responsible for a $50 copayment for a specialist visit. 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 $300 
copayment for in-network Medicare-covered outpatient hospital services.  
 
You have been asked to pay $115.98 for a hospital outpatient clinic visit. A hospital outpatient clinic visit falls 
within the Outpatient Hospital Services benefit category. Your contract with the Plan clearly says that you must 
pay a $300 copayment for an in-network hospital outpatient clinic visit. However, you have only been asked to 
pay $115.98 which is less than the $300 copayment amount. 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 hospital outpatient clinic visit on June 22, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for three ambulance rides and days 21 to 37 of 
a skilled nursing facility stay provided from  January 23, 2022, to March 13, 2022. 
 
You asked the Plan to waive the copayments for three ambulance rides and days 21 to 37 of a skilled nursing 
facility stay. You say that you would like these services covered. 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, and $188 per day for days 21 to 100 for ambulance services and skilled nursing facility (SNF) care.  
$188 per day x 16 days = $3,008. $250 x 3 ambulance rides = $750. $3,008 SNF stay + $750 ambulance rides 
= a total of $3758.  
You have been asked to pay a total of $3758 for three ambulance rides and days 21 to 37 of a skilled nursing 
facility stay. Three ambulance rides and days 21 to 37 of a skilled nursing facility stay falls within the 
Ambulance Services and Skilled Nursing Facility (SNF) 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 waive the copayments for three ambulance rides and days 21 to 37 of a skilled nursing facility stay provided 
from  January 23, 2022, to March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 9, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
  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 office visit provided on March 9, 2022, by an out-
of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and portable gaseous 
oxygen system (E1392). 
 
You asked the Plan to pre-approve an oxygen concentrator and portable gaseous oxygen system. You say that 
you disagree with the denial and would like to request reconsideration. The Plan denied your request. The Plan 
says Medicare rules state oxygen equipment is limited to 36 months of rental. Recertification is required for 
continued rental of oxygen and equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that oxygen equipment is limited to 36 months of 
rental.  
 
We looked at the file and Medicare rules. The records show you have been using oxygen since 2016, therefore, 
you will need recertification for continued use of the requested items. Based on this information, we decided 
that Medicare rules for coverage of an oxygen concentrator and portable gaseous oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390) and 
portable gaseous oxygen system (E1392).