Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. 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. 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 requested treatments are not medically necessary at the LTACH level of care. The 
enrollee has improved medically but continues to have active medical issues that require an acute care hospital. 
She can receive further care at the current acute care hospital or a lower level of care when deemed appropriate. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (96361, 96374) provided on April 18, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
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 payment for CPT codes 96361 and 96374 is not supported in the medical record. Specifically, 
these codes are assigned a PC/TC indicator of 5. This means that Payment may not be made by carriers for 
these services when they are provided to hospital inpatients or patients in a hospital outpatient department. As 
the services were billed with an outpatient place of service (23), these services are not payable. Based on this 
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (96361, 96374) provided on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 28, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294. 
 
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 
April 28, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, and 81294.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve angiography, extremity, unilateral, radiological 
supervision and interpretation, and angiography, extremity, bilateral, radiological supervision and 
interpretation. 
 
You asked the Plan to pre-approve angiography, extremity, unilateral, radiological supervision and 
interpretation, and angiography, extremity, bilateral, radiological supervision and interpretation. You say that 
angiography, extremity, unilateral, radiological supervision and interpretation, and angiography, extremity, 
bilateral, radiological supervision and interpretation is medically necessary. The Plan denied your request. The 
Plan says that requested services do not meet the Medicare NCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 angiography, extremity, unilateral, 
radiological supervision and interpretation, and angiography, extremity, bilateral, radiological supervision and 
interpretation. Our reviewer says that angiography, extremity, unilateral, radiological supervision and 
interpretation, and angiography, extremity, bilateral, radiological supervision and interpretation is not 
medically necessary. Our physician reviewer found that you were evaluated on September 8, 2022 for 
complaint of bilateral lower extremity weakness. Further details with respect to the lower extremity weakness 
is not provided nor is a description as to impact on function or quality of life. This evaluation did not 
incorporate the computed tomography angiography (CTA) performed on March 31, 2022 that did not 
demonstrate a significant stenosis, the essentially normal ankle-brachial index (ABI) on April 12, 2022, or the 
plain films of June 10, 2022 suggesting severe lumbar spine changes, and the lumbar spine MRI of June 24, 
2022. The plan was for you to get a CTA and have this reviewed with the physician. No further records are 
provided with respect to the subsequent evaluation or a rationale for the requested angiogram. It is not clear if 
you were seen by a spine specialist for an interpretation of your spine imaging in the context of leg weakness.   
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of angiography, extremity, unilateral, radiological supervision and interpretation, 
and angiography, extremity, bilateral, radiological supervision and interpretation have not been met. Therefore, 
we decided that the Plan does not have to pre-approve angiography, extremity, unilateral, radiological 
supervision and interpretation, and angiography, extremity, bilateral, radiological supervision and 
interpretation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided September 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that this claim should be paid. The Plan denied your 
request. The Plan says you are not a licensed Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who is not eligible for the Medicare program. Therefore, we decided that the Plan does not have to pay for the lab 
services provided September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81162) provided on April 29, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service 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 BRCA1 & 2 genetic testing is covered for patients 
with Breast cancer diagnosed at any age, and a family history of breast, ovarian, prostate or pancreatic cancer. 
 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 
records do not support the billed service. Our physician reviewer found the records do not show that coverage 
criteria has been met. There is no family history of breast, prostate, ovarian, or pancreatic cancer. 
 
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 (81162) provided on April 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for canalith repositioning therapy provided on 
May 9, 2022. 
 
You asked the Plan to waive the copayment for canalith repositioning therapy. You say that you are dissatisfied 
with this "therapy and feel you should not have to pay this copayment. The Plan denied your request. The Plan 
says the copayment that was applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for canalith repositioning therapy. Canalith repositioning therapy 
falls within the Outpatient Rehabilitation 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 canalith repositioning therapy provided on May 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs received from March 10, 2022, to March 24, 2022. 
 
You asked the Plan to pay for the drugs. You say that you have met your out-of-pocket maximum. The Plan 
denied your request. The Plan says the out-of-pocket maximum was met in June. 
 
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 an out-of-pocket maximum of $6700. 
 
The out-of-pocket maximum was not met until June 2022. You are still responsible for these services. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is an out-of-pocket maximum. This 
cost sharing is a contractual obligation. Therefore, we decided that the Plan does not have to pay for drugs 
received from March 10, 2022, to March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate gene expression profile (0005U). 
 
You asked the Plan to pre-approve a prostate gene expression profile. You say that the service at issue is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the 
requested service have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that EACH biomarker test is covered ONCE in men 
equal to or greater than 45 years old prior to initial biopsy, with confirmed moderately elevated PSA. 
 
We looked at the file and Medicare rules. In this case, the medical records document that the enrollee's PSA is 
elevated beyond the limit (equal to or greater than 10 ng/mL) specified in the rules. Based on this information, we decided that Medicare rules for coverage of a prostate gene expression profile have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a prostate gene expression profile (0005U).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service March 1, 
2022. 
 
You asked the Plan to pay for procedure code 95941. You say that this should be covered. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 95941 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 95941 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 95941 billed for date of service March 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from January 24, 
2022, to January 29, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you feel this is a billing error, 
this copayment is too high. The Plan denied your request. The Plan says the copayment that was applied was 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 
copayment per day for days 1 to 5 for in-network inpatient hospital care.  
 
You have been asked to pay a $1875 copayment for a 5-day inpatient stay ($375 x 5 = $1875). An inpatient 
stay falls within the In-Network Inpatient Hospital 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 inpatient stay provided from January 24, 2022, to January 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for office visit and Part B drug on February 
28, 2022. 
 
You asked the Plan to waive the cost sharing for office visit and Part B drug. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost sharing you are being charged 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for each Medicare-covered visit with a specialist. Covered services include consultation, diagnosis, 
and treatment by a specialist. The provider billed in the amount of $2.50 for Part B drugs. $45 + $2.50 = 
$47.50. Therefore, results in the total cost sharing amount of $47.50. You have been asked to pay a $45 copayment for office visit and $2.50 Part B drug. Office visits and Part B 
drug falls within the Physician/practitioner services, including doctor's office visits and What you pay for your 
Part D prescription 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. Therefore, we decided that the Plan does not have to waive the cost sharing for office visit 
and Part B drug on February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Aranesp provided on March 23, 2022. 
 
You asked the Plan to pay for Aranesp. You say that you had authorization to provide this drug. The Plan 
denied your request. The Plan says you did not bill correctly for this drug because you did not bill an OPPS-
payable procedure code along with the drug. 
 
The Plan must follow Medicare rules. Medicare rules say that claims with a pass-through drug or biological 
that lab an Outpatient Prospective Payment System (OPPS) payable procedure (i.e., those with a status 
indicator of  J1, J2, P, Q1, Q2, Q3, R, S, T, U, V) will be denied with Outpatient Code Editor Edit 99.  The 
Aranesp you provided is a pass-through drug, so you have to bill an OPPS-payable procedure code with it.  The 
only procedure codes you billed with the Aranesp are 36415 and 85025.  Both of these codes have an OPPS 
status indicator of Q4, which is not indicative of an OPPS-payable procedure.  Because you did not bill the 
Aranesp with an OPPS-payable procedure, the claim cannot be paid.  The Plan has indicated that it would be 
willing to reconsider its denial should you submit a corrected claim. 
 
We looked at 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 pay for Aranesp 
provided on March 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 29, 2022. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial for 
services rendered to the enrollee on date of service April 29, 2022. 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 laboratory services provided on April 29, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health social worker visit provided on April 22, 
2022. 
 
You asked the Plan to pay for the home health services. You say that this should be paid because the enrollee 
did receive skilled services during the prior certification period, from March 15, 2022, through April 13, 2022. 
This should be paid as this was a continuation of the same episode of care. The Plan denied your request. The 
Plan says this claim was billed with no skilled services, meaning it is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that certification periods in which dependent services 
are rendered but not followed by a skilled service are not covered, unless the reason that a skilled service was 
not provided was an unexpected discharge, such as those due to hospital admission or death. 
 
 We looked at the file and Medicare rules. In this case, only a single dependent service was billed for this 
certification period. The claim indicates that the patient's status code was 01, meaning a routine discharge. 
Since the enrollee's discharge was not due to an unexpected reason, payment cannot be made for this period of 
care. Based on this information, we decided that Medicare rules for coverage of the home health services have 
not been met. Therefore, we decided that the Plan does not have to pay for the home health social worker visit 
provided on April 22, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
December 30, 2021. 
 
You asked the Plan to pay for a domiciliary or rest home visit. The Plan denied your request. The Plan says the 
member was in hospice on this date of service. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a domiciliary or rest home visit provided on 
December 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services on December 25, 
2021, to December 26, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital services. You say that you never left the ER, 
and you were never admitted. The Plan denied your request. The Plan says the claims submitted by the 
Hospital, as well as the related medical records support the inpatient level of care. 
 
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 $200 
copayment for inpatient hospital services.  
 
You have been asked to pay a $200 copayment for inpatient hospital services. Inpatient hospital services falls 
within the inpatient hospital 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 
inpatient hospital services on December 25, 2021, to December 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on May 12, 2022, by an 
out-of-network (OON) provider.