Persius/hicric huggingface dataset:
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 
December 15, 2021. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were under the impression that 
you were being admitted as an inpatient. 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 $50 
copayment for each emergency room visit. If you are held for observation, the copayment still applies.  
 
The file shows that you were kept under observation care only. Therefore, you have been asked to pay a $50 
copayment for the ER visit. The 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 December 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MTHFR gene analysis. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the clinical documentation does not support that MTHFR gene analysis is medically reasonable and 
necessary for the enrollee in this case. The documentation does not support that MTHFR is an accepted 
standard of medical practice with clinical utility, that is at least as beneficial as existing and available medically 
appropriate alternatives. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MTHFR gene analysis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
December 22, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network 
care have not been met. 
 
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 domiciliary or rest home visit (99336) provided 
on December 22, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 21, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you sent medical records to show medical 
necessity. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 21, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Arthroplasty, knee, condyle and plateau (27447) provided 
January 18, 2022. 
 
You asked the Plan to pay for the surgical procedure. You say that due to network insufficiency, the out of 
network provider was the only available assistant at the time of the procedure and rendered services 
specifically requested by the in-network primary physician and in-network facility. The Plan denied your 
request. The Plan says registered nurse first assistants are not recognized as physicians per Medicare 
guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for Arthroplasty, knee, condyle and 
plateau (27447) provided January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp/home modification (S5165) and a 
stair lift (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp and a stair lift. You say that due to a rare side effect of 
chemo, you have been diagnosed with neuropathy causing you to be totally paralyzed from the waist down and 
it is not reversible. You need these items to and from the hospital for cancer treatments frequently and daily 
living purposes. You do not consider this a convenience, you consider this a necessity because due to your 
immobility, physically, you cannot navigate up or down the stairs. The Plan denied your request. The Plan says 
the requested items are not medically necessary as Medicare does not consider stair lifts to be medical in 
nature, and wheelchair ramps are not considered as DME. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules also say that for equipment to be covered, it must be appropriate and needed for use 
inside the home.   
 
The stair lift 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. The wheelchair ramp is for use outside 
of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use 
outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp/home 
modification (S5165) and a stair lift (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says laboratory testing related to treatment of end-stage renal disease is bundled into dialysis services 
and is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1392) and backpack (E1399) 
purchased October 25, 2021. 
 
You asked the Plan to pay for the oxygen equipment. You say that you are requesting reimbursement of the 
oxygen equipment. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for 
coverage. Purchased oxygen equipment and accessories are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at t the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the oxygen equipment have not been met. Therefore, we decided that the Plan does not have to pay 
for the oxygen concentrator (E1392) and backpack (E1399) purchased October 25, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF 
care. The Plan denied your request. The Plan says the enrollee's condition does not require daily 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 
the criteria for coverage have not been met. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. The records do not show the need for intravenous medications, new 
tube feeding, ostomy care, or daily complex wound care. The enrollee does require skilled therapy services, but 
not on a daily basis. The enrollee is walking household distances with a rolling walker and is supervision to 
contact guard assist for transfers. The provided records do not document a significant decline in the enrollees 
functional status to necessitate daily inpatient skilled therapy services. The records do not document that 
services in the home or an assisted living facility with home health care or in a long-term care facility on a part 
time basis are not appropriate in this case. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
February 9, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the transportation 
was necessary after surgery since you could not walk. 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 $250 
copayment for each one-way ambulance trip.  
 
 
 You have been asked to pay $234, which is less than the $250 copayment for the ambulance transportation. 
The 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 copayment for ambulance transportation provided on February 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81292, 81206, 81295, 81298) provided 
December 24, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this test was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the test results 
provide the clinician with information that will improve patient outcomes and/or change physician care and 
treatment of the patient. 
 
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 the genetic testing. Our reviewer says that 
this test was not medically necessary. Our physician reviewer found Tempus gene testing has not been FDA-
approved, and the clinical documentation does not support that the results will improve the enrollee's outcome 
and/or change the treatment regimen. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for genetic testing (81292, 81206, 81295, 81298) provided December 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten occupational therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that the enrollee demonstrates good rehab potential, as 
evidenced by active participation in skilled treatment, active participation with plan of treatment, compliance 
with techniques, supportive staff, and strong family support. The Plan denied your request. The Plan says the 
documentation provided is not supportive that the unique and sophisticated skills of an occupational therapist 
are required to continue treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.  
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 visits. Our reviewer says that skilled 
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. 
Our physician reviewer found that the enrollee has dementia and generalized weakness, but does not meet the 
coverage criteria for the requested additional visits. The documentation does not support the need for 10 
additional occcupational therapy visits, which are not medically necessary for coverage. There is no 
documentation to address the need and effectiveness for these additional visits. The enrollee has received ten 
therapy visits so far, and showed improvement. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve ten occupational therapy visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from January 10, 2019, through 
January 11, 2019, at DRG 326. 
 
You asked the Plan to pay for inpatient services at DRG 326. You say that Q25.79 is clinically valid as a 
secondary diagnosis for this admission and the coding is support by the official guidelines. You say that DRG 
326 is the correct DRG for this admission. The Plan denied your request. The Plan says diagnosis code Q25.79 
was removed which resulted in a change from DRG 326 to DRG 328. 
 
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 with diagnosis code Q25.79, defined as other congenital 
malformations of pulmonary artery. 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 326. Our reviewer says that the change to DRG 328 is appropriate. Our physician 
reviewer found the documentation does not support that diagnosis code Q25.79 was reasonable and necessary 
to include in this case as a diagnosis code.  
 
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 January 10, 2019, through January 11, 2019, at DRG 326.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Aranesp. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record does not indicate that the 
enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic screening panel (81479) provided 
on October 11, 2021. 
 
You asked the Plan to pay for the cardiovascular genetic screening panel. You say that you would like this 
claim reprocessed based on medical necessity. The Plan denied your request. The Plan says the ordered lab 
testing services were a screening panel that is not eligible for coverage. 
 
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 pay for the cardiovascular genetic screening panel. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested genetic testing is medically 
appropriate and necessary. The test is described as a genetic based cardiovascular risk factor screening test in 
which multiple genes are assessed using genomic DNA extracted from patient sampling. It assesses the 
presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac 
risk. It is not a diagnostic test. There is no evidence to support its role in this patient clinical management. In 
summary, the requested testing is not considered reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the cardiovascular genetic screening panel have not been met. Therefore, we 
decided that the Plan does not have to pay for the cardiovascular genetic screening panel (81479) provided on 
October 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve opening of the blood vessels with balloon, stent or 
calcium cutting device. 
 
You asked the Plan to pre-approve opening of the blood vessels with balloon, stent or calcium cutting 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 opening of the blood vessels with 
balloon, stent or calcium cutting device. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the record provided does not 
establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service at 
this time. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of opening of the blood vessels with balloon, stent or calcium cutting device have 
not been met. Therefore, we decided that the Plan does not have to pre-approve opening of the blood vessels 
with balloon, stent or calcium cutting device.