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

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 9, 2021.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says an edit exits between CPT codes 71045 and 71046.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on August 9, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan from the skull base to
mid-thigh
You asked the Plan to pre-approve PET scan services. You say that the requested imaging service is medically
necessary. The Plan denied your request. The Plan says that you have already completed three PET scans and a
fourth is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan services. Our reviewer says
that the requested PET scan is medically reasonable and necessary. Our physician reviewer found you have a
history of relapsing B cell lymphoma. You have had multiple cycles of chemotherapy and most recently
chimeric antigen receptor T cells (CAR-T) therapy in June 2021. In this case, you require a follow-up PET scan
to search for stability of abnormal findings on prior PET scans after this new therapy concluded. Therefore, the
requested service should be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of PET scan services have been met. Therefore, we decided that the Plan has to
pre-approve a positron emission tomography (PET) scan from the skull base to mid-thigh
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pharmacogenomic panel provided on April
7, 2020.

You asked the Plan to pay for the comprehensive pharmacogenomic panel. You say that you would like
reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says a
panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel.

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, the comprehensive pharmacogenomic panel, was requested solely for screening
purposes. The documentation does not show that the requested pharmacogenomic testing was ordered due to
any signs/symptoms of a drug reaction. There is no evidence that the testing was provided for therapeutic
decision-making regarding the need for the use of any specific drug. Medicare does not cover this test solely
for screening purposes. Therefore, we decided that the Plan does not have to pay for a comprehensive
pharmacogenomic panel provided on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bioimpedance spectroscopy using the ImpediMed L-
Dex device 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 medical studies have not proven that this device is helpful for treatment of the health
problem.
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 based on the medical records provided, there is no documentation that the assessment with bioimpedance
spectroscopy using the ImpediMed L-Dex device at issue in this case meets Medicare criteria for medically
reasonable and necessary. Current recommendations of the peer reviewed medical literature on bioimpedance
spectroscopy using the ImpediMed L-Dex device for conditions such as this enrollee's does not meet Medicare
criteria for medically reasonable and necessary for the assessment, treatment or prevention of lymphedema.
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 bioimpedance spectroscopy using the ImpediMed L-Dex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81270, 81403, G0452) provided on June
28, 2021.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says the records do not include a physician order.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must
be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician.
We looked at the file and Medicare rules. The submitted documentation does not include a physician order or
records from the ordering physician. Based on this information, we decided that Medicare rules for coverage of
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory
services (81270, 81403, G0452) provided on June 28, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the standard of care for prostate cancer would be standard radiation therapy including intensity-modulated radiation therapy (IMRT).
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found whether proton therapy for prostate cancer affords any advantage over IMRT is very controversial. The enrollee is being offered pelvic/prostate radiotherapy (50.4-56 Gy in 28 fractions) with a cone down boost of 22 Gy in 11 fractions. No comparison plan is provided for this enrollee showing an unacceptable non-proton based plan. The only comparison provided is for a 'model patient' for which reduction in median dose is provided. Even with this model patient, there is no plausible claim that the non-proton plan would be unacceptable using standard normal tissue constraints. Routine use of proton therapy for pelvic/prostate radiation is not within accepted standards of medical practice.
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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a romosozumab injection provided on July
7, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that this was previously billed as an
office visit. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Part B drugs, including osteoporosis drugs.
You have been asked to pay a $377.58, which is 20% of the allowed amount for the romosozumab injection
($1887.90 allowed amount x 20% coinsurance = $377.58). The injection falls within the Medicare Part B
Prescription Drugs benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a romosozumab
injection provided on July 7, 2021.
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 this is medically necessary. The Plan denied your
request. The Plan says the enrollee's care needs could be met with either admission to a skilled nursing facility
or home health.

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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were treated for a
tibial plateau fracture and are living at home with ongoing difficulties with self-care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the medical record supports a need for physical and/or occupational therapy, there is no
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee injections provided on April 7, 2021, to April 28,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the knee injections. You say that you sent in all the claim information and the
reimbursement was denied. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the knee injections provided on April 7, 2021, to April 28, 2021,
by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on June 17, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were having a
hypoglycemic attack and your blood sugar was below 30 and you had to call for help as you did not know what
was happening. You say that the emergency medical services (EMS) were able to get you stabilized and you
did not need to go to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit
is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 17, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant
(D6010).
You asked the Plan to pre-approve an endosteal implant. You say that this service is medically necessary. The
Plan denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) provided May 18, 2021.
You asked the Plan to pay for the chiropractic office visit. You say that there was no consultation. You brought
your MRI scan results with you from your spine doctor. He did a hip and spinal manipulation the same visit.
You wasn't any different than any other appointment. The Plan denied your request. The Plan says this service
is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the outpatient office visit (99202) provided May 18, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no documentation of the status of the family members with pancreatic cancer.
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, the testing, is being requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve
BRCA testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from December 31, 2020, to January 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this should be
processed under your 2020 benefits. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that this was processed under your 2020 benefits.
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 $270
copayment per day for days 1-8,and a $0 copayment for additional days for inpatient hospital care.
Records show that you were in the hospital for 10 days. You were charged a $270 copayment per day for each
of the first 8 days, for a total of $2160. 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 inpatient
hospital services you received from December 31, 2020, to January 9,2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or an assisted living facility with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 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: Imaging
Decision: Unfavorable

We decided that the Plan has to reduce the copayment for the ophthalmology services you had on September 1,
2021.
You asked the Plan to reduce the copayment for the ophthalmology services. You say that your copayment for
this service should be $15. The Plan denied your request. The Plan says that you were charged this copayment
correctly.
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 enrollees must pay a $15 copayment for Medicare-covered vision care services.
The Plan says you must pay a $25 copayment for the ophthalmology services because the services are
considered specialist services. Based on the Plan contract however, you cannot be asked to pay more than a $15
copayment for the ophthalmology services. The ophthalmology services you received are Medicare-covered
vision care services which have a $15 copayment. Therefore, we decided that the Plan has to reduce the
copayment for the ophthalmology services you had on September 1, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.
You asked the Plan to pre-approve 5 additional home health physical therapy visits. You say that this additional
care is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for
additional home health care have not been met.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 5 additional home health physical
therapy visits. Our reviewer says that the requested home health services are not medically reasonable and
necessary. Our physician reviewer found In this case, the documentation does not support that the member
requires additional skilled home health aide (HHA) services or skilled rehab services to provide treatment that
is medically necessary. The member does not require additional HHA services or skilled rehab services to
effectively provide treatment, care, and/or services in order to improve the member's condition, perform a
maintenance program to maintain the member's condition and/or prevent deterioration. The member has been
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The
requested home health services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 5 additional home health physical therapy visits have not been met. Therefore,
we decided that the Plan does not have to pre-approve 5 additional home health physical therapy visits.