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

 
We decided that the Plan does not have to pay for the genetic testing provided on February 9, 2022, billed with 
codes 81227, 81230, 81231, 81323, 81306, 81291, 81328, 81355, 81335, 0031U, 0032U, 0033U, 81407, 81406 
and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as 
required by Medicare billing regulations. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 9, 2022, billed with codes 81227, 81230, 81231, 81323, 81306, 81291, 81328, 81355, 81335, 0031U, 
0032U, 0033U, 81407, 81406 and 81238.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the physical therapy evaluation visit 
provided on January 27, 2021. 
 
You asked the Plan to waive the deductible for physical therapy. You say that the enrollee did not have 
physical therapy and should not be responsible for this cost. The Plan denied your request. The Plan says this 
claim was processed in accordance with the enrollee's contract. The Plan also states that they are reviewing 
your potential fraud concerns in a separate case. 
 
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 $750 deductible which applies to outpatient rehabilitation services.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 
$750 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time physical therapy was received on January 27, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for the physical therapy evaluation visit provided on 
January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 17, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service March 17, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for injections you received at your neurologist's office on February 23, 
2022. 
 
You asked the Plan to pay for the injections with a neurologist. You say that these injections have been paid in 
the past. The Plan denied your request. The Plan says that these services were less than a month after previous 
injections and you are only getting limited benefit from these injections.  There is no documentation of 
extenuating circumstances showing that a fourth set of injections was medically necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided these services by a contract provider. The file does not show that the Plan provided notice 
that the injections would not be covered prior to the services being rendered. Under Medicare rules, this means 
the injections are considered approved by the Plan. Therefore, we decided that the Plan has to pay for injections 
you received at your neurologist's office on February 23, 2022.  
 
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 a lumbar orthosis (brace) provided on 
January 31, 2022. 
 
You asked the Plan to waive the coinsurance for the lumbar brace. You say that you were informed there was 
no cost to you for the brace. 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 prosthetic devices and supplies, including braces.  
 
You have been asked to pay $44.90, which is 20% of the allowed amount for the lumbar brace ($224.51 
allowed amount x 20% coinsurance = $44.90). The lumbar brace falls within the Prosthetic Devices 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 a lumbar orthosis 
(brace) provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting. 
 
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 have a past medical 
history of poliomyelitis, femur fracture repair in 2019 and chronic left knee pain and are living at home with weakness. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, per day, for the evaluation 
and management of a patient (99309) provided on January 24, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for OON subsequent nursing facility care. You say that the facility should have 
obtained authorization. The Plan denied your request. The Plan says the OON care was not pre-authorized and 
does not meet criteria for coverage. 
 
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 subsequent nursing facility care, per day, for the 
evaluation and management of a patient (99309) provided on January 24, 2022, by an out-of-network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) and a receiver (monitor) to use with CGM (K0554). 
 
You asked the Plan to pre-approve a supply allowance and receiver for a CGM. You say that the enrollee 
would benefit from a CGM for insulin dose adjustments based on glucose levels. The Plan denied your request. 
The Plan says the enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a supply 
allowance and receiver for a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) and a receiver 
(monitor) to use with CGM (K0554).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for X-rays March 03, 2022. 
 
You asked the Plan to waive the copayment for X-rays. You say that you were dissatisfied with the service and 
feels the service was not needed. The Plan denied your request. The Plan says the cost-sharing you are being 
charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment per visit for Medicare-covered X-rays. Covered services include but are not limited to: X-rays. 
 
You have been asked to pay a $15 copayment for X-rays. X-rays 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 
X-rays March 03, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator garment 
provided from February 6, 2022, to March 6, 2022. 
 
You asked the Plan to waive the coinsurance for an automatic external defibrillator garment. You say that you 
were unaware there would be a coinsurance for this item. The Plan denied your request. The Plan says the 
coinsurance applied was 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 a 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item is $3080.95 resulting in a 
coinsurance amount of $616.19 ($3080.95 x 20% = $616.19). You had two months with this item ($616.19 x 2 
= $1,232.38). 
 
You have been asked to pay a $1,232.38 coinsurance for an automatic external defibrillator garment. an 
automatic external defibrillator garment falls within the durable medical equipment (DME) and related 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 coinsurance for an automatic external 
defibrillator garment provided from February 6, 2022, to March 6, 2022.  
 
Your complaint about not being aware of your coinsurance amount 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: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the neuropsychological testing (96132 & 96133) and neurobehavioral 
exam (96116) provided on February 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient mental health services. You say that these services were referred 
by your physician because there were no in-network providers available. The Plan denied your request. The 
Plan says that the services were provided out-of-network and were not approved in advance. 
 
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 clarified the network status of the referring provider in this 
case. Without this information, we cannot determine if the services were plan directed care. Medicare rules say 
that a contract provider is an agent of the plan. Services and referrals given by a contract provider are 
considered approved by the plan unless notice is provided that the services will not be covered. The Plan 
follows these rules. Therefore, we decided that the Plan has to pay for the neuropsychological testing (96132 & 
96133) and neurobehavioral exam (96116) provided on February 17, 2022, by an out-of-network (OON) 
provider.  
 
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 and the destruction of benign lesions other 
than skin tags or cutaneous vascular proliferative lesions provided on September 9, 2021, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for an office visit and the destruction of benign lesions other than skin tags or 
cutaneous vascular proliferative lesions provided. You say that the claim was processed incorrectly with the 
facility national provider identifier (NPI) and not the rendering provider as it should. The Plan denied your 
request. The Plan says care received from an out-of-network provider will not be covered, and there is no 
authorization on file. 
 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 and the destruction of benign 
lesions other than skin tags or cutaneous vascular proliferative lesions provided on September 9, 2021, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on April 26, 
2022. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound should be included 
with your screening mammogram. 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 $10 
copayment for each advanced radiology service, including ultrasounds.  
 
You have been asked to pay a $10 copayment for the ultrasound. The ultrasound 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 breast ultrasound provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
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 does not meet the Medicare criteria for admission to an Inpatient 
Rehabilitation Facility (IRF). 
 
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 admitted for knee surgery including excision of heterotropic bone. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (64634) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or 
CT); cervical or thoracic, single facet joint (64633). 
 
You asked the Plan to pre-approve cooled radiofrequency ablation. You say that the requested procedure is 
necessary. The Plan denied your request. The Plan says the requested procedure does not meet criteria. 
 
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 cooled radiofrequency ablation. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member. There is insufficient evidence in the literature on the effectiveness of cooled radiofrequency ablation 
for treating facet joint pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cooled radiofrequency ablation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with 
imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (64634) and destruction 
by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or 
thoracic, single facet joint (64633).