Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve electrophysiologic study and catheter ablation of atrial fibrillation 
(93656). 
 
 
You asked the Plan to pre-approve catheter-based ablation. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage of the 
requested services have not been met. 
 
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 pre-approve catheter-based ablation. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found at issue is the appropriateness and medical necessity of performing 
electrophysiologic study and catheter ablation of documented, symptomatic atrial fibrillation. Records 
document clinical improvement in sinus rhythm, which was transiently achieved following electrical 
cardioversion. Recent guidelines have reflected clinical studies consistent with catheter ablation as acceptable 
first-line therapy in the management of symptomatic atrial fibrillation compared with antiarrhythmic drug 
therapy.  As a result, at this time electrophysiologic study and catheter ablation of atrial fibrillation would be 
considered medically reasonable and appropriate 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 catheter-based ablation have been met. Therefore, we decided that the Plan has 
to pre-approve electrophysiologic study and catheter ablation of atrial fibrillation (93656). 
  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel provided on April 16, 2021, billed 
with 10 individual codes. 
 
You asked the Plan to pay for the Tempus Gene Panel as billed. You say that this testing has many studies 
which support it and should be covered. The Plan denied your request. The Plan says this testing panel must be 
billed using a single code. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 
 In this case, the single panel analyzes multiple genes. As such, the use of 10 codes to describe this panel is not 
appropriate based on Medicare coding rules. Therefore, we decided that the Plan does not have to pay for the 
Tempus Gene Panel provided on April 16, 2021, billed with 10 individual codes.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain 
rendered on October 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography 
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with 
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the 
head/brain rendered on October 17, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says that CPT code 80050 is not payable by Medicare; therefore, the claim cannot be 
reconsidered and will be upheld. 
 
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 did not provide an Explanation of Benefits to show what services are 
being denied and why. Therefore, the denial is not substantiated by the Plan. Therefore, we decided that the 
Plan has to pay for the laboratory services provided on November 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pregabalin capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee had good results with this 
drug and has failed trials of gabapentin. The Plan denied your request. The Plan says the denial of authorization 
for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer 
the enrollee's Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve pregabalin capsules.  
 
Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for brachytherapy isodose intermediate 
(77317) and radiation physics consultation (77370) services provided on October 8, 2021. 
 
You asked the Plan to waive the coinsurance for the brachytherapy isodose intermediate and radiation physics 
consultation. You say that the services should be covered. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the brachytherapy isodose intermediate and radiation 
physics consultation services (total allowed is $422.11 x 20% = $84.42). Brachytherapy isodose intermediate 
and radiation physics consultation 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 waive the coinsurance for brachytherapy isodose 
intermediate (77317) and radiation physics consultation (77370) services provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered on July 19, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the 
OPPS, but their payment is packaged into payment for a separately paid service. 
 
We looked at the file and Medicare rules. The file shows that no submitted HCPCS codes were eligible for 
separate payment.  
 
 
 
 Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the outpatient hospital services rendered on July 
19, 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 SNF care is medically necessary and beneficial 
to the enrollee. The Plan denied your request. The Plan says the criteria for coverage have not been met. The 
Plan says that the enrollee can get the care needed in another setting. 
 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 
daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital 
the enrollee had stabilized medically.  The enrollee did not require any skilled nursing or rehabilitation services 
on a daily basis at an inpatient level of care.  She was not expected to make measurable gains within a 
reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or 
self-care tasks.  The enrollee did not require skilled therapy to establish a safe and effective maintenance 
program.  As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF 
level of care at the time of discharge from the hospital. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube.  She was medically stable without any acute 
exacerbations of chronic medical problems.  Her physical function was at or near her baseline and she could 
have received further services at a lower level of care. Admission to the nursing facility at a skilled level of 
care for inpatient skilled services was not 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 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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require can safely be received at a different setting. 
 
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 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on September 3, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a 
network provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 services provided on September 3, 2021, by an 
out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for blood bank physician services (86077) provided on October 
31, 2021. 
 
You asked the Plan to pay for blood bank physician services. You say that this service was billed correctly. The 
Plan denied your request. The Plan says this service has a maximum allowable unit of service (UOS) of 1 for 
the same date of service per the MAI indicator of "2". This service was billed twice for the same date, and the 
first unit has been paid. The second unit does not meet Medicare rules for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of blood 
bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for blood 
bank physician services (86077) provided on October 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
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. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on July 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual 
psychotherapy (90837, 90834) provided October 21, 2021 to November 4, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that you had three sessions with this 
provider which you paid a total of $75. You were told twice by two different Plan representatives that this is a 
covered service. The Plan denied your request. The Plan says the services were rendered by a licensed clinical 
professional counselor (LCPC). An LCPC is not eligible in the Medicare program. 
 
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 integrated biopsychosocial assessment 
(90791) individual psychotherapy (90837, 90834) provided October 21, 2021 to November 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided on 
September 27, 2021. 
 
You asked the Plan to waive the deductible for the inpatient hospital stay. You say that the services should be 
covered. The Plan denied your request. The Plan says the deductible 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. Your 
contract with the Plan says that there is a $750 copayment which applies to Inpatient hospital care.  
 
 
  The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient 
hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
copayment which applies to Inpatient hospital care. This cost sharing is a contractual obligation that had not 
been met at the time the inpatient hospital stay was received on September 27, 2021. Therefore, we decided 
that the Plan does not have to waive the deductible for an inpatient hospital stay provided on September 27, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
October 17, 2021, to October 25, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the services should be 
covered. 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 $500 
copayment for Inpatient hospital care.  
 
 
 You have been asked to pay a $500 copayment for an inpatient hospital stay. 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 inpatient hospital stay provided from October 17, 2021, to October 25, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the CT scan, thorax, diagnostic; with contrast material(s) (CPT 
code 71260). 
 
You asked the Plan to pre-approve the CT scan. You say that the enrollee has been diagnosed with melanoma 
of the skin with metastasis to lung, liver and brain stage IV. You state the CT still showing ground glass 
opacity with pulmonary nodules/inflammation. The Plan denied your request. The Plan says that the recent 
findings of the same CT scan conducted in January of this year did not reveal interval changes from previous 
studies and the submitted documentation from the provider does not support a repeat of this CT scan at this 
time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pre-approve the CT scan. Our physician reviewer 
found the notes include inflammatory or infectious disease as well as metastases to explain the ground glass 
nodules. Despite stability in size differentiation is necessary for treatment. Consideration is being given to 
bronchoscopy for diagnosis. A surveillance CT prior to invasive procedure is reasonable. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve the CT scan, thorax, diagnostic; with contrast material(s) (CPT code 71260).  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. The enrollee 
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for LTACH services. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.