Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on March 01, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you are requesting to settle this bill 
because you can afford any more payments. 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 $170 
copayment for each Medicare-covered service at an ambulatory surgical center. If you are having surgery in a 
hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. 
Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay 
the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be 
considered an outpatient. The provider billed in the amount of $3,500 and the allowed amount is $107.23. 
This is less than the copayment amount. Therefore, results in the total cost sharing amount of $107.23. 
 
 You have been asked to pay a $107.23 copayment, which is less than the copayment for injections. This 
item/service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 injections 
on March 01, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DetermaRx 14-Gene Lung Cancer Assay (0288U) 
provided April 15, 2022. 
 
You asked the Plan to pay for the DetermaRx 14-Gene Lung Cancer Assay. You say that the enrollee meets 
criteria for this test. The Plan denied your request. The Plan says Medicare billing criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes, modifiers and in this case an identifier, based on the 
Medicare LCD guidelines applicable to the service. Medicare requires claims for this type of testing to be 
billed with a unique test identifier. 
 
We looked at the file and Medicare rules. Based on L35160, this requirement is applicable as the claim shows 
the lab test was rendered in California. The LCD indicates all tests billed within this jurisdiction are required to 
be billed with a Unique Test Identifier. We find do not find this identifier was billed on the claim. Based on 
this information, we decided that Medicare rules for coverage of the DetermaRx 14-Gene Lung Cancer Assay have not been met. Therefore, we decided that the Plan does not have to pay for the DetermaRx 14-Gene Lung 
Cancer Assay (0288U) provided April 15, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay skilled nursing facility (SNF) care after 
October 9, 2022. 
 
You asked the Plan to pre-approve continued stay skilled nursing facility (SNF) care after October 9, 2022. 
You say that would benefit from continued stay skilled nursing services due to your medical complexity. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for continued stay SNF care and can 
be treated in a 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 continued stay SNF care. Our reviewer 
says that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines. Our physician reviewer found daily skilled services are not necessary. Our physician reviewer 
found that the medical records do not document that you require services on an inpatient basis, only in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued stay SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued stay skilled nursing facility (SNF) care after October 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and waive the copayment for chiropractic manipulative 
treatment and an office visit provided by a chiropractor on May 18, 2022. 
 
You asked the Plan to pay for and waive the copayment for chiropractic treatment and office visit. You say that 
you should only be responsible for the $20 copayment because you went to an in-network provider. 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 
copayment for each in-network chiropractic visit. The only covered chiropractic service is manual 
manipulation of the spine to correct a subluxation.  
You have been asked to pay $20 copayment for chiropractic treatment and office visit. This item/service falls 
within the Chiropractic 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. Additionally, the office visit provided is not covered by Medicare or the Plan 
when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for and waive the 
copayment for chiropractic manipulative treatment and an office visit provided by a chiropractor on May 18, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the leg cast provided on June 20, 2022. 
 
You asked the Plan to pay for the services provided. You say that the service may be billed separately. The 
Plan denied your request. The Plan says the documentation does not support the separate reporting. 
 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, the CPT Code Manual definition of code 29445 is application of rigid total contact leg cast. We 
find that CPT code 29445 is not supported. Casting codes shall not be reported for application of a dressing 
after a therapeutic procedure. The medical records provided do not show that code 29445, billed with the -59 
modifier was a distinct procedural service. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the leg cast provided on June 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost for the stent placement provided on October 13, 
2021. 
 
You asked the Plan to reduce the cost for outpatient surgery. You say that you were taken to a room, and this 
should be considered inpatient. The Plan denied your request. The Plan says outpatient surgery coinsurance 
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 20% 
coinsurance per visit for outpatient surgery.  
 
You have been asked to pay $3,756.99 for outpatient surgery. This item/service falls within the outpatient 
surgery benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to reduce the cost for the stent placement provided on 
October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 1, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81291, 81335, 0031U, 0032U, 81407, 0033U, 
81406, and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 
March 1, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81355, 81291, 81335, 0031U, 
0032U, 81407, 0033U, 81406, and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on December 3, 2021, by an 
OON provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are asking for an exception to be made 
regarding covering the services provided and grant a retro authorization. The Plan denied your request. The 
Plan says the out-of-network services were not authorized. 
 
 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 outpatient surgery provided on December 3, 2021, 
by an OON provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services (81455) provided on April 18, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the laboratory services (81455) provided on April 18, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 27, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing is covered by Medicare. The Plan 
denied your request. The Plan says coverage criteria have not been met. 
 
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, the CPT Code Manual definition of code 81162 is BRCA1 (BRCA1, DNA repair associated), 
BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full 
sequence analysis and full duplication/deletion analysis. 
 
We find that CPT code 81162 is not supported in the medical record. Although the enrollee has a personal 
history of breast cancer, they do not meet all of the coverage criteria required. Therefore, we decided that the 
Plan does not have to pay for the genetic testing provided on April 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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, 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. 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 November 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92014) 
provided on May 16, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92014). You say that this was a 
routine eye examination, 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 $35 
copayment for a specialist's office visit.  
 
 
  You have been asked to pay a $35 copayment for a medical eye examination (92014). This item/service falls 
within the vision 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. The record shows that the Plan reached out to the provider and the provider said they 
waived the copayment. Therefore, we decided that the Plan does not have to waive the copayment for a 
medical eye examination (92014) provided on May 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a membrane skin graft. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
request 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 requested services. Our physician 
reviewer found that the enrollee is suffering with recalcitrant ulcerations to their right lower extremity. Since 
March 9, 2022, the ulcerations have reduced only slightly in area. The enrollee has been undergoing routine 
debridement with dressing changes by home health nursing. They have also been non weightbearing. Recent 
vascular evaluation demonstrates severe arterial sclerosis to the right lower extremity. It has been 
recommended that the enrollee be treated with a skin substitute graft. It is well documented that this enrollee is 
suffering with severe peripheral arterial disease. Until the enrollee is re-vascularized, it does not appear that 
these grafts will be beneficial as they do require a good vascular supply in order to incorporate with the 
enrollees body. Therefore, the requested skin substitute graft is not medically reasonable or necessary for this 
enrollee at this time. 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a membrane skin graft.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis of the sacroiliac joint (SIJ). 
 
You asked the Plan to pre-approve arthrodesis of the SIJ. 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. 
 
The Plan follows Medicare rules. Medicare rules say that percutaneous minimally invasive fusion/stabilization 
of the sacroiliac joint (SIJ) for the treatment of back pain is indicated for the treatment of SIJ pain for patients 
with low back/buttock pain who meet specific criteria. 
 
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 arthrodesis of the SIJ. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the objective exam findings 
do not demonstrate tenderness with palpation of the posterior SI joint in the absence of tenderness of similar 
severity elsewhere. The exam also fails to demonstrate positive sacroiliac provocative testing. There are noted 
x-rays of the lumbar spine and sacroiliac joints; however, there are no computed tomography (CT) or magnetic 
resonance imaging (MRI) of the lumbar spine provided to rule out neural compression or other degenerative 
condition that can be causing low back or buttock pain. Therefore, the enrollee does not meet the coverage 
criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis of the SIJ have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis of the sacroiliac joint (SIJ).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve placement of an ILR. 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. 
 
The Plan follows Medicare rules. Medicare rules say that cardiac event monitors are covered when specific 
criteria are met.  
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 placement of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found while the enrollee has a history of 
stroke and atrial fibrillation, there is no documentation provided to suggest a history of unexplained syncope or 
any other apparent indication for an ILR. In summary, there is insufficient documentation to support the 
medical necessity for insertion of an ILR in this enrollees 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 placement of an ILR have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of an implantable loop recorder (ILR).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bi-level pressure capability device and supplies. 
 
You asked the Plan to pre-approve bi-level pressure capability device and supplies. 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. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 bi-level pressure capability device and 
supplies have been met. Specifically, medical records were not received. Medical necessity cannot be 
established without this documentation. Therefore, we decided that the Plan does not have to pre-approve bi-
level pressure capability device and supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kesimpta. 
 
You asked the Plan to pre-approve Kesimpta. You say that Kesimpta is medically necessary. The Plan denied 
your request. The Plan says this drug is self-administered and not eligible for coverage under the Part B 
medical benefit. 
 
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 Kesimpta.  
 
Benefits for Kesimpta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.