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

 
We decided that the Plan does not have to pay for the comprehensive cancer panel provided on April 21, 2022. 
 
You asked the Plan to pay for the testing services. You say that the treatment sought was medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says one code must be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the comprehensive cancer panel provided on April 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on April 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing is necessary for therapeutic decision 
making. The Plan denied your request. The Plan says the claim was billed with an inconsistent date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the next generation sequencing was billed with a date of service when the test was performed. 
However, there are insufficient records to show the coverage criteria for the billed date of service have been 
met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on April 5, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on September 13, 2021. 
 
You asked the Plan to pay for the testing services. You say that the test distinguishes those at increased risk for 
prostate cancer. The Plan denied your request. The Plan says the test is not a Medicare benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
We looked at the file and the rules. There are no medical records from the treating physician to show how the 
results will impact clinical management. A biopsy would still need to be provided regardless of the outcome of 
the testing at issue. The testing services were requested for screening purposes. Medicare does not cover this 
testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing 
services provided on September 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services provided on December 31, 
2021. have been met. The submitted documentation does not contain medical records from the non-contract provider. Therefore, we decided that the Plan does not have to pay for the services provided on December 31, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injection provided on May 06, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you were advised that you only had 
a $30 copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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% 
coinsurance for Part B drugs. 
 
 
 
 
 
 
 
 You have been asked to pay 20% coinsurance for the injection. This item/service falls within the Part B 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. The 
allowed amount for the injection is $2,346.00, and the 20% coinsurance is a total of $469.20. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the injection provided on May 06, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and 
clearly exceeds the Medicare guidelines for an appropriate long term acute care hospital admission. The Plan 
denied your request. The Plan says admission to LTACH was denied as not meeting criteria, is not medically 
necessary, and continued acute hospital stay was offered, until the member could discharge to a lower level of 
care. 
 
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. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with pneumonia, congestive heart 
failure (CHF), urinary tract infection, and acute respiratory failure complicated by dysphagia. The enrollee was 
treated with high flow oxygen, BiPAP, diuresis, antibiotics, and parenteral nutrition (TPN). Recent notes 
describe the enrollee with resolving CHF and weaning, now tolerating high flow oxygen with BiPAP only as 
needed, but with x-ray findings showing persistent pneumonia and still dependent on TPN.  The enrollee appears to still be somewhat unstable but improving and should only require short-term additional 
acute care services that can safely be administered at the current facility until more stable and appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not available at the current 
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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PriMatrix (skin substitute) per square centimeter 
(Q4110) application of a skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; 
first 25 sq. cm or less wound surface area (15271). 
 
You asked the Plan to pre-approve PriMatrix. You say that you have been going to this provider for your 
wound care and you are appealing this denial. The Plan denied your request. The Plan says based on the 
submitted documentation PriMatrix 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 PriMatrix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee is quadriplegic. The notes from your provider show that 
there is a pressure ulcer (pressure sores) on the right knee. The notes do not show that the enrollee has diabetic 
ulcers or Venous insufficiency ulcers. The review has determined that the items/services at issue in this case 
are 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 PriMatrix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PriMatrix (skin substitute) per square centimeter (Q4110) application of a skin substitute graft 
to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area 
(15271).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Ramucirumab provided on March 30, 
2022. 
 
The enrollee asked the Plan to waive the coinsurance for the Ramucirumab. The enrollee said that they have 
had this procedure done many times in the past and it has always been covered. The Plan denied the enrollees 
request. The Plan says the coinsurance amount the enrollee has been charged is correct. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan 
contract says that enrollees must pay a 20% coinsurance for Medicare Part B prescription drugs. 
 
The enrollee has been asked to pay a 20% coinsurance for the Ramucirumab. Ramucirumab falls within the 
Medicare Part B prescription drugs 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 
coinsurance for the Ramucirumab provided on March 30, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can be met at an alternate lower level of care. 
 
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 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. There 
are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The 
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does 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 the enrollee's condition does not meet Medicare criteria for SNF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from November 26, 2021, 
through December 1, 2021, at DRG 177. 
 
You asked the Plan to pay for inpatient services at DRG 177. You say that the medical records make it clear 
that the enrollee's acute hypoxic respiratory failure was directly related to the reason for admission and 
treatment. You say that J96.01 is clearly billed appropriately as the secondary diagnosis code and the claim 
should be paid under the billed DRG of 177. The Plan denied your request. The Plan says secondary diagnosis 
code of J96.01 did not qualify for reporting. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, defined as acute 
respiratory failure with hypoxia. 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 inpatient 
services at DRG 177. Our reviewer says that the medical documentation does not support the use of diagnosis 
code J96.01. Our physician reviewer found that the enrollee was admitted for aspiration pneumonia and a 
diagnosis of hypoxia was not determined.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from November 26, 2021, through December 1, 2021, at DRG 177.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve right shoulder arthroscopy services. 
 
You asked the Plan to pre-approve right shoulder arthroscopy services. You say that this procedure is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
not medically reasonable and necessary at this time. 
 
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 right shoulder arthroscopy services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 65-year-old female being treated for stiffness in the 
shoulder not elsewhere classified. They presented with a persistent painful range of motion in the right 
shoulder. They are currently working in therapy and not making a lot of progress. In this case, detailed 
documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive 
conservative care measures. The results from the injection on July 21 are not provided. Moreover, there are no 
detailed objective findings provided to support limited motion of the shoulder. There are limited large-scale, 
long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested right shoulder arthroscopy, 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 right shoulder arthroscopy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve right shoulder arthroscopy services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 18, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. 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 May 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth therapy visit provided on May 
24, 2022. 
 
You asked the Plan to waive the copayment for telehealth therapy visit. You say that you thought the first 6 
visits were covered with no copayment. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
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 $30 
copayment for outpatient mental health care. 
 
 
 
 
 
 You have been asked to pay a $30 copayment for telehealth therapy visit. This item/service falls within the 
outpatient mental health 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 telehealth 
therapy visit provided on May 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
18, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the transportation was 
arranged by the hospital without your consultation. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 $250 
copayment for ambulance services. 
 
 
 
 
 
 
 You have been asked to pay a $250 copayment for the ambulance services. This item/service 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 the ambulance 
services provided on May 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 receiver device for the enrollee. 
 
You asked the Plan to pre-approve a Dexcom G6 receiver device. You say that this is medically necessary. The 
Plan denied your request. The Plan says that the enrollee does not meet 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 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 Dexcom G6 receiver device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 receiver device for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 1, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the specimen was 
obtained in an office setting. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. The claim in this case was billed with the laboratory POS code. The 
records do not support that the sample was taken in a laboratory setting. Based on this information, we decided 
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan 
does not have to pay for lab services provided on February 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical pulley system. 
 
You asked the Plan to pre-approve a surgical pulley system. You say that this item is necessary for your 
condition. The Plan denied your request. The Plan says this equipment is not covered by either Medicare or the 
Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a surgical pulley system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart device. 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an Optimizer Smart device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found while the clinical studies led to FDA approval in 2019, cardiac contractility 
modulation (CCM) remains the subject of multiple studies examining long-term efficacy, as well as 
randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous 
studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, the CCM 
system is not considered to be medically necessary in this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an Optimizer Smart device.