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

 
We decided that the Plan does not have to pay for the Unlisted molecular pathology procedure, Cxbladder urine 
test (81479) provided June 2, 2021. 
 
You asked the Plan to pay for the Cxbladder urine test. You say that you disagree with this decision and request 
prompt review of this information and authorization of coverage for the Cxbladder triage test. The Plan denied 
your request. The Plan says this service is unproven and not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Cxbladder urine test is considered not medically necessary in the 
treatment of asymptomatic blood in the urine. Research has not shown this test to have better outcomes than 
standard methods of diagnosis. Based on this information, we decided that Medicare rules for coverage of the CX bladder urine test have not been met. Therefore, we decided that the Plan does not have to pay for the 
Unlisted molecular pathology procedure, Cxbladder urine test (81479) provided June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aflibercept injection (J0178) provided 
on January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the aflibercept injection. You say that the services should be 
covered as you disagree with the charges. 
 The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided. 
 
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 Medicare Part B prescription drugs, and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for the aflibercept injection (allowed is $1,831.50 x 20% = 
$366.30). Aflibercept injections 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 waive the coinsurance for an aflibercept injection (J0178) provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services.  
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests (87426) purchased on January 
15, 2022. 
 
You asked the Plan to pay for the home COVID-19 tests. You say that you needed these tests urgently and they 
should be covered. The Plan denied your request. The Plan says home COVID-19 tests are an over-the-counter 
item, which means they are not covered by Medicare or the Plan. COVID-19 tests are covered in full when you 
receive them from a laboratory, pharmacy, doctor or hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and a home 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for the at-home 
COVID-19 tests (87426) purchased on January 15, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home care services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was clinical documentation was submitted to substantiate the medical necessity. 
 
 
 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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that you require additional skilled nursing services to provide treatment that is medically 
necessary. You do not require additional skilled nursing services to effectively provide treatment, care, and/or 
services in order to improve your condition, perform a maintenance program to maintain your condition and/or 
prevent deterioration. You have 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve additional home care services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the vision services (V2799) provided on November 16, 
2021. 
 
You asked the Plan to hold you harmless for the vision service. You say that you do not understand what the 
Plan's denial means, but you do know that you selected a standard frame, and you did not choose any extras for 
your eyeglasses aside from progressive lenses. The Plan denied your request. The Plan says that lens options 
are not covered without the purchase of a base lens. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules also say that providers must report services correctly. Providers must report services 
with the appropriate CPT code. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not substantiate their denial with any receipts or 
documentation to definitively verify the services that were purchased on this date. Code V2799 is defined as 
vision item or service, miscellaneous. A miscellaneous code is not reported to the highest specificity. From the 
case file provided, we cannot verify that this service is a lone lens upgrade and not a full pair of eyeglasses. The 
provider in this case is contracted with the Plan. It is the contracted providers job, as an agent of the Plan, to 
report services correctly. Incorrect billing by a network provider is not the responsibility of the enrollee. Therefore, we decided that the Plan has to hold you harmless for the vision services (V2799) provided on 
November 16, 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 pay for an office visit provided on September 10, 2021, by an OON 
provider. 
 
You asked the Plan to pay for the office visit. You say that your office had Medicare as the enrollee's primary 
coverage and not the Plan. Also, the service rendered to the enrollee was out of medical necessity. The Plan 
denied your request. The Plan says the rendering provider is an OON provider and there was no referral from 
an in-network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 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 an office visit provided on September 10, 2021, by 
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shoulder arthroscopy 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 is not medically necessary. 
 
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 detailed documentation is not evident regarding diagnostic imaging corroborated pathology. The MRI 
did not corroborate pathology that could potentially be treated with the requested procedure. There are limited 
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical 
setting. Recent comprehensive and reasonable less invasive treatments have not been documented. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception to guidelines. Therefore, the requested left shoulder arthroscopy (29822), in this case, is 
not medically reasonable or necessary. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a shoulder arthroscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on December 6, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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 service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on December 6, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each 
additional 15 minutes (97811) provided November 17, 2021. 
 You asked the Plan to pay for the acupuncture services. You say that as per the enrollee's benefits and 
eligibility which were confirmed by your office, this is a covered service. The Plan denied your request. The 
Plan says services were rendered by a non-covered provider type. 
 
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 file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, services were rendered by a licensed acupuncturist, 
not a physician. The health Plan contract specifically says that the service must be provided by a legally 
qualified physician practicing within the scope of their license. Therefore, we decided that the Plan does not 
have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) 
provided November 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Botulinum injection provided on January 
20, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that you feel a second $15 copayment is 
inappropriate because your specialist copayment is $15 not $30. The Plan denied your request. The Plan says 
you have been 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 $15 
copayment for Part B drugs administered by a health care professional. The contract also says that an office 
visit copayment may apply. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$15 copayment for an injection. An 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 copayment for a Botulinum injection provided on January 20, 
2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for physician's services provided on September 29, 2021. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that prior 
authorization and/or referral may be required. Your delegated group advises there was no authorization on file. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided us with the name and network status of the referring 
provider. Therefore, we decided that the Plan has to pay for physician's services provided on  
September 29, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy 
electrical pump (E2402) provided from October 1, 2021, to October 24, 2021. 
 
You asked the Plan to waive the coinsurance for the negative pressure wound therapy electrical pump. You say 
that the services should be covered as you disagree with the charges. The Plan denied your request. The Plan 
says the coinsurance applied correctly based on the services provided. 
 
 
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 Durable medical equipment (DME) and related supplies.  
 
 You have been asked to pay a 20% coinsurance for the negative pressure wound therapy electrical pump 
(allowed is $2,640 x 20% = $528). Negative pressure wound therapy electrical pumps fall within the Durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the negative pressure wound therapy electrical pump (E2402) provided from October 1, 2021, 
to October 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve the 12 additional home health physical therapy visits. You say that you 
would like reconsideration because the requested home health services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the home 
health services. 
 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 the 12 additional home health physical 
therapy visits. Our reviewer says that the documentation doesnt support that the member requires additional 
skilled rehab services to provide treatment that is medically necessary. The member does not require additional 
skilled rehab services to effectively provide treatment, care, and/or services in order to improve their condition, 
perform a maintenance program to maintain their condition and/or prevent deterioration. Our physician 
reviewer found 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 the 12 additional home health physical therapy visits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve 12 additional home health physical therapy 
visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on December 14, 
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 a professional component (PC)/technical component 
(TC) indicator of 3 represents TC only codes. 
 
We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no 
separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services rendered on December 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy in your home (G0151 x 13). 
 
You asked the Plan to pre-approve home health care. You say that the only caregiver you have is your husband. 
You say that he is not able to perform the therapy that you need. You also say that the requested services are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not require skilled services. 
 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 home health care. Our reviewer says 
that the requested home health care is not medically necessary. Our physician reviewer found the 
documentation does not support that you require additional skilled rehab services to provide treatment that is 
medically necessary. The reviewer found that you do not require additional skilled rehab services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable 
without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer 
found that 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 home health care have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy in your home (G0151 x 13).