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

 
We decided that the Plan does not have to pay for the genetic testing services provided on November 16, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that 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, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
 
 
 
 We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this 
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we 
decided that the Plan does not have to pay for the genetic testing services provided on November 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular, including imaging guidance and device evaluation (33274) for the 
enrollee. 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that records do not indicate that the enrollee will be 
enrolled in an FDA approved study. 
 
The Plan must follow Medicare rules. Medicare limits coverage of leadless pacemakers to those provided 
within a study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Specifically, there was no documentation that the leadless 
pacemaker is being provided as part of a Medicare-approved study. This service is not covered unless part of a 
Medicare-approved study. Therefore, we decided that the Plan does not have to pre-approve transcatheter 
insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance and 
device evaluation (33274) for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the x-ray services provided on July 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the professional reading must be billed 
separately from the technical charge. The Plan denied your request. The Plan says that the modifier is not 
supported. 
 
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. 
 
In this case, the professional component (modifier 26) of the knee x-ray is at issue. We looked at the file and 
the rules. The Plan denied services since both claims were billed to the mobile x-ray provider. The case file, 
however, does not include the claim for the technical component. The Plan has not made reasonable and 
diligent efforts to gather and forward to us information regarding their decision to deny your request.  
Therefore, we decided that the Plan has to pay for the x-ray services provided on July 13, 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 radiofrequency ablation (RFA) of the sacroiliac joint. 
 
You asked the Plan to pre-approve RFA of the sacroiliac joint. You say that the records provided support the 
need for the requested services. The Plan denied your request. The Plan says sacral lateral nerve branch blocks 
and/or ablations to treat pain in the joint that connects the pelvis to the tailbone (sacroiliac joint) are not 
supported by research and not covered. 
 
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 RFA of the sacroiliac joint. Our 
reviewer says that RFA of the sacroiliac joint is not considered medically reasonable and necessary. Our 
physician reviewer found the enrollee has chronic low back pain and sacroiliitis. She underwent bilateral 
sacroiliac (SI) joint injections on May 3, 2022 and achieved 90% pain relief for 2 weeks. There is a wide 
variation in efficacy reported in literature regarding RFA of the sacroiliac joint. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac joint.
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 you would like to appeal the denial of the 
authorization. The Plan denied your request. The Plan says the denial of the acute inpatient rehabilitation 
admission was appropriate given the clinical scenario. 
 
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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not require intensive physician and nursing oversight in an IRF. While the patient may 
benefit from additional multiple therapies, including physical and occupational therapy, the documentation 
does not reveal that the patient requires this therapy on an intensive IRF level. 
 
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: 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 the service is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 there is no documentation that the patient requires the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. 
 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic assay rendered on January 25, 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed 
adjacent to the CPT code for GeneSight testing. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX 
Z-Code. 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 GeneSight Psychotropic assay 
rendered on January 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87798, and 87801 
billed for date of service October 15, 2021. 
 
You asked the Plan to pay for procedure code 87481, 87640, 87653, and 87798. You say that you disagree with 
the denial. The Plan denied your request. The Plan says payment for codes 87481, 87640, 87653, and 87798 is 
bundled into payment for code 87801. 
 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 codes 
87481, 87640, 87653, and 87798 are column II codes to column I code 87801. 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.  
 
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 87801 is infectious agent detection by nucleic acid (DNA 
or RNA), multiple organisms; amplified probe(s) technique. 
 
We find that CPT code 87801 is not supported in the medical record. Specifically, there is no lab report or 
results for this test in the submitted documentation. 
 
Therefore, we decided that the Plan does not have to pay for procedure codes 87481, 87640, 87653, 87798, and 
87801 billed for date of service October 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $650 copayment for ambulance transportation provided on 
February 19, 2022. 
 
You asked the Plan to waive the $650 copayment for ambulance transportation provided on February 19, 2022. 
You say that you were told there would be a $40 copayment if you used a chair car, but that you were not given 
this option. The Plan denied your request. The Plan says you are responsible for a $325 copayment per one-
way trip for covered ambulance services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). There were 2 one-way trips provided, resulting in a total copayment 
amount of $650. Your contract with the Plan clearly says that you must pay a $325 copayment per one-way trip 
for ambulance services.  
 
You have been asked to pay a $650 copayment for ambulance transportation. Ambulance transportation 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 waive the $650 copayment 
for ambulance transportation provided on February 19, 2022. Your complaint about being told there would be a 
$40 copayment 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you no longer require skilled services. 
 
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 services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy 
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient 
basis in a skilled nursing facility setting. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment for a biopsy performed on November 2, 
2021. 
 
You asked the Plan to waive the $100 copayment for a biopsy performed on November 2, 2021. You say that 
you are appealing the assessed copayment. The Plan denied your request. The Plan says you are responsible to 
pay a $100 copayment for each outpatient surgical procedure. 
 
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 $100 
copayment for Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay a $100 copayment for a biopsy performed on November 2, 2021. A biopsy falls 
within the Outpatient Surgery, Including Services Provided At Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 $100 copayment for a biopsy 
performed on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the 14 extractions (D7140) provided on November 9, 
2021, by the out of network provider. 
 
You asked the Plan to pay more for the dental services. You say that you just found out that this provider was 
out of network. You say that you would never be able to pay this bill. You say that you are on Social Security. 
You also say that the dental office was dishonest with you. The Plan denied your request. The Plan says you 
are responsible for any charged amount above the Plans cost sharing amount when your services are received 
from an out of network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out of network providers charges and the Plans 
payment. 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 pay more for the 14 extractions (D7140) provided on 
November 9, 2021, by the out of network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on February 1, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that your doctor told you to go to the ER so it 
should be covered. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay $100 
copayment for each emergency room visit.  
 
You have been asked to pay $100 copayment for ER visit. ER visits fall within the Emergency 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 copayment for ER visit provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services and imaging guidance rendered on 
February 8, 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 the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 surgical services and imaging guidance rendered on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic and office visit provided on April 6, 2022 by 
an OON provider. 
 
You asked the Plan to pay for a chiropractic and office visit. You say that the provider is appealing the claims 
for the services rendered. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 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 a chiropractic and office visit provided on April 6, 
2022 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an OON provider. 
 
You asked the Plan to pre-approve office visits. You say that you are requesting to have the in-network benefits 
for an out-of-network provider. You say that until recently the provider was in the Plan's network. The Plan 
denied your request. The Plan says the requested service is available within an in-network Plan facility. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visits to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from January 25, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayment for SNF care. You say that due to financial hardships you think the 
copayment should be waived. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay $20 
copayment per day for days 1 through 20. $0 additional for days 21through 100.  
 
 
 
 
 
 You have been asked to pay $400 ($20 x 20 days) copayment for SNF care. SNF care falls within the 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 copayment for SNF care 
provided from January 25, 2022, to February 25, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on February 2, 2022, and February 5, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that these 
services were for medical treatment, and you feel you should not be charged. The Plan denied your request. 
The Plan says this service is not covered. The Plan also says that you were aware of the risk of refusal for 
transport, and you signed the refusal form. 
 
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 February 2, 2022 to February 5, 2022. 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 the ambulance response 
and treatment with no transport (A0998) provided on February 2, 2022, and February 5, 2022.