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

 
We decided that the Plan does not have to pay for genetic testing (81479) provided July 17, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the billed service is not eligible for coverage as a screening test. 
 
The Plan must follow Medicare rules. Medicare rules say that rules state that only the following codes are to be 
billed for Cardiovascular Disease Screening: 80061 - Lipid Panel, 82465 - Cholesterol, serum or whole blood, 
total, 83718 - Lipoprotein, direct measurement, high density cholesterol, & 84478 - Triglycerides. 
 
We looked at the file and Medicare rules. A genetic cardiovascular risk assessment (81479) is not eligible for 
coverage as a Cardiovascular Disease Screening test. Based on this information, we decided that Medicare 
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have 
to pay for genetic testing (81479) provided July 17, 2021.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has 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 home health services. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has documented 
complex neurological impairments including right hemiplegia and aphasia, still requiring moderate to 
maximum assist with mobility. Documented clinical case would require a professional therapist to assist with 
treatments as reasonable documented goals have not yet been reached. 16 additional home health physical 
therapy sessions are medically reasonable and effective at treating the condition. 
 
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 services have been met. Therefore, we decided that the Plan has to 
pre-approve home health physical therapy visits.  
 
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 pay for a powered recliner (E0627, S9999) provided December 4, 
2021. 
 
You asked the Plan to pay for the powered recliner. You say that you purchased a floor model chair from the 
furniture store because of supply chain issues with network providers. The Plan denied your request. The Plan 
says the supplier does not participate in Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a powered recliner (E0627, S9999) 
provided December 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for knee replacement surgery, lab services, 
and physical therapy services provided from February 22, 2022, to February 23, 2022.  
 
You asked the Plan to reduce the copayment for knee replacement surgery, lab services, and physical therapy 
services. You say that you were told you only had a $290 copayment for the knee replacement.  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 $290 
copayment for in-network outpatient surgery at an ambulatory surgical center. The Plan contract also says that 
enrollees must pay a $30 copayment for an in-network physical therapy visit. The Plan contract also says that 
enrollees must pay a $10 copayment for in-network lab services. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$290 copayment for knee replacement surgery on February 22, 2022. Knee replacement surgery falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. You have been asked to pay a $30 copayment for physical therapy services on 
February 23, 2022. Physical therapy services fall within the Outpatient Rehabilitation Services benefit 
category.   
 
You have been asked to pay the allowed amount of $3.93, which is less than the $10 copayment for lab 
services on February 22, 2022. You have also been asked to pay a $10 copayment for lab services on February 
23, 2022. Lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and 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 reduce the copayment for knee replacement surgery, lab 
services, and physical therapy services provided from February 22, 2022, to February 23, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for unna boot strapping provided from January 
11, 2022, to February 21, 2022.  
 
You asked the Plan to waive the copayment for unna boot strapping. You say that you should not have to pay a 
facility care for what equates to an office visit. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $390 copayment for each outpatient surgery visit.  
 
The enrollee has been asked to pay the allowed amount of $151.09, which is less than the $390 copayment for 
each unna boot strapping on January 11, 2022, and January 18, 2022. The enrollee has also been asked to pay 
the allowed amount of $155.52, which is less than the $390 copayment for each unna boot strapping on 
February 7, 2022, February 10, 2022, and February 21, 2022.  Unna boot strapping falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 unna boot strapping provided 
from January 11, 2022, to February 21, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cervical x-rays provided from August 10, 
2021, to October 27, 2021.  
 
You asked the Plan to waive the deductible for the x-rays. You say that there is no copayment for x-rays. 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. Your 
contract with the Plan says that there is $300 deductible which applies to out-of-network x-rays.  
 
The record shows the x-rays were applied to your deductible. The item or service you asked the Plan to waive 
the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 
deductible which applies to out-of-network x-rays. This cost sharing is a contractual obligation that had not 
been met at the time the x-rays was received on August 10, 2021, to October 27, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for cervical x-rays provided from August 10, 2021, to 
October 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the 
lumbar spine provided on November 12, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you are on a fixed income and cannot 
afford this payment. 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 $175 
copayment for diagnostic radiology services, including MRIs.  
 
You have been asked to pay a $175 copayment for an MRI. An MRI falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and 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 copayment 
for a magnetic resonance imaging (MRI) of the lumbar spine provided on November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency transportation provided on 
March 14, 2021. 
 
You asked the Plan to waive the copayment for emergency transportation. You say that you were transported to 
the hospital by the fire department. You also say that the charges were false based on not being transported by 
an actual ambulance. 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 $260 
copayment for out-of-network emergency transportation.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$260 copayment for emergency transportation. Emergency 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 copayment for emergency transportation 
provided on March 14, 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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the 
service is not medically necessary. Our physician reviewer found the enrollee does not have documented 
skilled nursing needs or documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs are 
custodial and, as a practical matter, can be provided at a lower level of care. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit (99283) 
provided on January 31, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 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 $90 
copayment for Emergency care.  
 
 
  You have been asked to pay a $90 copayment for an ER visit. 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 an emergency room (ER) visit (99283) provided on January 31, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
February 28, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you were instructed to go to the ER 
after your lab work came back with abnormal levels. 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 $90 
copayment for an emergency room visit.  
 
You have been asked to pay a $90 copayment for an ER visit. An ER visit falls 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 an emergency room (ER) visit 
provided on February 28, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for a duplex scan of extremity veins including responses to compression 
and other maneuvers (93970) provided on June 24, 2021. 
 
You asked the Plan to pay for a duplex scan of extremity veins. The Plan denied your request. The Plan says 
that a duplex scan of extremity veins does not meet criteria. 
 
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 pay for a duplex scan of extremity veins. Our 
reviewer says that the requested duplex scan of extremity veins including responses to compression and other 
maneuvers is considered medically reasonable and necessary in this case. Our physician reviewer found that 
the documentation supports the medical necessity of the study in question. There is documentation that the 
enrollee is experiencing lower extremity pain, weakness, difficulty walking, tenderness, and swelling. In this 
setting it would be important to rule out lower extremity Deep vein thrombosis. Lower extremity venous 
duplex is a reasonable and medically necessary study to evaluate.  
 
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 duplex scan of extremity veins have been met. Therefore, we decided that the 
Plan has to pay for a duplex scan of extremity veins including responses to compression and other maneuvers 
(93970) provided on June 24, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS device 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the clinical evidence and FDA 
approval for a CardioMEMS support the use of this requested device. You say that the CardioMEMS implant is 
medically reasonable and necessary. The Plan denied your request. The Plan says the requested device is 
considered investigational and is not covered unless the enrollee is in an approved clinical trial. 
 
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 a CardioMEMS device. Our reviewer 
says that a CardioMEMS device is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS device
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA to the SI joint. You say that this is medically necessary for the your 
condition. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 to the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you are a 65-year-old male with a history of low back pain due to sacroiliitis. 
Your provider has recommended a sacroiliac joint (SIJ) radiofrequency ablation (RFA). 
 
According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis 
and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies 
completed say that this procedure does not improve outcomes compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed 
radiofrequency, is considered investigational and therefore, not medically necessary. The review has 
determined that the requested SI RFA 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 enrollee is medically stable with no new or acute medical problems and does not 
need PM&R physician supervision 3 times per week (at a minimum) for the ongoing management of any active 
or acute exacerbations of chronic medical conditions. The enrollee does not need intensive therapies, consisting 
of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an IRF. She 
will not tolerate the intensity of IRF. While the enrollee may benefit from physical therapy (PT) and 
occupational therapy (OT), her rehab needs can be met safely and provided at a lower intensity and alternate 
setting such as in a skilled nursing 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.