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

 
We decided that the Plan does not have to waive the cost sharing for the Part B drugs and related hospital 
services you received from July 14, 2021, to October 17, 2021. 
 
You asked the Plan to waive the cost sharing for the Part B drugs and related hospital services. You say that 
you believe you had met your out-of-pocket maximum prior to receiving these services.  You said that you 
received a letter on February 5, 2022, advising you that you had reached your out-of-pocket maximum for 2021 
after the processing of a claim for date of service August 5, 2021. The Plan denied your request. The Plan says 
you had not yet met your out-of-pocket maximum on the dates of service in question.  The Plan provided you a 
detailed explanation in its letter to you dated June 17, 2022, explaining how all of your cost sharing was 
calculated for these services and how your out-of-pocket maximum was applied.  In addition, the Plan advised 
you that the letter you received on February 5, 2022, was erroneous and you had not yet actually met your out-
of-pocket maximum. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs, including chemotherapy drugs. For the drug that is infused, you will 
pay this cost sharing.  In addition, for the administration of infusion drugs, you will pay the cost sharing that 
applies to outpatient hospital services. You pay a $195 copayment for surgery or other services provided in an 
outpatient hospital facility. 
 
You have been asked to pay 20% coinsurance for the Part B drugs and up to a $195 copayment for each of the 
related hospital services. This means that you have been asked to pay the correct amounts 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 the Part B drugs and 
related hospital services you received from July 14, 2021, to October 17, 2021.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an emergency room visit on March 22, 2022. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the enrollee reported to 
the emergency room following a rheumatology appointment with findings of elevated liver enzymes. You say a 
computed tomography (CT) scan was ordered at the emergency room. The scan results indicated an inflamed 
liver and a possibility of bile duct obstruction. However, you say the enrollee was sent home in tremendous 
pain. The following day, the enrollee went to a primary care physician. The doctor reviewed the CT scan and 
advised the enrollee should be admitted immediately. You say the enrollee was officially diagnosed with liver 
cancer and an additional scan revealed a spot on the enrollees lung also. The Plan denied your request. The 
Plan says that the claim was processed correctly with a copayment of $90 for services provided in the 
emergency room. 
 
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 appeal request indicates that the enrollee was admitted to the hospital for the 
same condition within three days of the initial visit. However, the Plan does not address this matter in the 
decision, nor does the Plan provide any evidence to suggest that this is false. We reviewed the file and found 
evidence that the enrollee was admitted as an inpatient to the hospital on March 24, 2022. A claim from March 
24, 2022, clearly shows Current Procedural Terminology (CPT) code 99222, which is an inpatient hospital 
code. Since this date of service is only two days after the initial emergency room visit, we decided that the Plan 
has to waive the copayment for an emergency room visit on March 22, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy (G6015, 77386, G6002, 77387). 
 
You asked the Plan to pre-approve radiation therapy. You say that therapy is medically necessary and medical 
records were submitted to confirm treatment is necessary. The Plan denied your request. The Plan says that 
radiation therapy does not meet Medicare criteria for coverage. 
 
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 radiation therapy. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a diagnosis of stage IIIA small cell lung cancer. The enrollee has been treated 
with chemotherapy and external beam radiation therapy. The prophylactic use of IMRT cranial irradiation is 
supported in the NCCN Guidelines Version 2.2022 Small Cell Lung Cancer. "Hippocampal-avoidance (HA) 
PCI using IMRT may be considered as a potential strategy to improve cognitive preservation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-
approve radiation therapy (G6015, 77386, G6002, 77387).  
 
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 diagnostic medial branch blocks (MBBs). 
 
You asked the Plan to pre-approve diagnostic MBBs. You say that these injections are medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the requested facet joint intervention 
services are not medically reasonable and necessary. 
 The Plan follows Medicare rules. Medicare rules say that facet joint interventions are subject to the criteria 
listed in the Medicare rules section. 
 
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 diagnostic MBBs. Our reviewer says 
that the criteria for the requested diagnostic MBBs have not been met. Our physician reviewer found that the 
documentation notes that the enrollee had an epidural injection on January 11 and had relief for 2 days before 
returning to baseline. The enrollee does still have radiating pain down both legs. Furthermore, the assessment 
on the progress note states that the enrollee has a complaint of lumbar radiculopathy most likely from 
discogenic causes. The cited imaging shows more left sided pathology, and the assessment reflects patient with 
more right sided symptoms. The criteria state that there should be an absence of untreated radiculopathy or 
neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst) prior to the requested 
medial branch blocks. The documentation does not reveal an absence of untreated radiculopathy. There is no 
evidence of a synovial cyst on lumbar imaging. Therefore, the enrollee does not satisfy the listed Medicare 
coverage criteria for MBBs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic MBBs have not been met. Therefore, we decided that the Plan does 
not have to pre-approve diagnostic medial branch blocks (MBBs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a separate contract with the 
dialysis facility for these lab services. The Plan denied your request. The Plan says these lab services are not 
separately payable. 
 
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 
lab services provided on January 24, 2022.
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 it is felt that LTACH care would be best 
for this enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
care at the current hospital and can remain there until ready for discharge to a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a male who was admitted to the acute care hospital for coronary artery 
revascularization surgery and mitral valve repair complicated by hypotension, acute kidney injury, blood loss 
anemia, atrial fibrillation, delirium, and deconditioning. He was treated with hemodialysis, tube feeds, and 
physical therapy. Recent notes describe the enrollee as now advancing oral food, with stable vitals, and stable 
kidney function on dialysis.  
 
 The enrollee appears to be more stable and improving and should only require short-term additional acute care 
hospital services that can safely be completed at the current facility until more appropriate for a lower level of 
care. The enrollee does not require services at the LTACH that are not already available at the current facility.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
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 enrollee is stable and suitable for 
LTACH admission. He requires prolonged hospitalization and monitoring of his conditions. The Plan denied 
your request. The Plan says LTACH admission is not medically necessary. 
 
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 patient is a 72 year-old male who was admitted to the acute care hospital with 
stridor, acute respiratory failure, recent COVID-19 infection, transaminitis, pneumonia, complicated by 
encephalopathy, requiring trach placement and mechanical ventilation support as well as antibiotics and tube 
feeds. He was weaned to BiPAP. Recent notes state that PEG was placed, he is now tolerating 5L via trach 
collar mask and has completed antibiotics. The patient appears to be more stable and improving and should 
only require short-term additional acute care hospital services that can safely be completed at the current 
facility until more appropriate for a lower level of care. The patient does not require services at the LTACH 
that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Transfer to LTACH is not medically 
necessary as it would not be clinically advantageous. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided 
November 23, 2021 to November 29, 2021. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF 
services provided. The Plan denied your request. The Plan says the enrollee did not meet the Medicare criteria 
for continued SNF level of coverage.  
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 pay for the SNF services. Our reviewer says that the 
Medicare criteria for continued SNF level of coverage were not met Our physician reviewer found there are no 
identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or 
therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an 
inpatient basis in a skilled nursing facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided November 23, 2021 to November 29, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 27, 2021 billed with 
codes 81194, 81206, 81210, 81235, 81272, 81275, 81276, 81317, 81311, 81292, 81295, and 81298. 
 
You asked the Plan to pay for the genetic testing as billed. You say that this is medically necessary testing that 
should be covered. The Plan denied your request. The Plan says this cannot be covered because only tests with 
Food and Drug Administration (FDA) approval are covered by Medicare. 
 
Please note: The rationale cited by the Plan is not applicable in this case. Though the National Coverage 
Determination referenced does limit national coverage to FDA-approved tests, it also allows local Medicare 
contractors to determine coverage criteria for non-FDA tests. Since the coverage rule is not applicable, we have 
reviewed based on the coding of this NGS panel. 
 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 as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on August 27, 2021 billed with codes 81194, 81206, 81210, 81235, 81272, 81275, 81276, 81317, 
81311, 81292, 81295, and 81298.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for targeted genomic sequence analysis panel, 51 or greater genes (81455) 
provided December 12, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that FoundationOne Heme was ordered by the 
treating physician because the test results were needed to help determine the course of treatment for this 
enrollee. The Plan denied your request. The Plan says that the services does not meet Medicare NCD/LCD 
criteria. 
 
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 pay for the genetic testing. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found several gene mutations have been identified among patients with MDS that may, in part, 
contribute to the clinical heterogeneity of the disease course, and thereby influence the prognosis of patients. 
Such gene mutations will be present in the majority of newly diagnosed patients, including most patients with 
normal cytogenetics. Several studies examining large numbers of MDS tumor samples have identified more 
than 40 recurrently mutated genes with greater than 80% of patients harboring at least one mutation. This can 
also add in guiding treatment decision making. Use is supported by the NCCN Guidelines. The service was 
reasonable and 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 genetic testing have been met. Therefore, we decided that the Plan has to 
pay for targeted genomic sequence analysis panel, 51 or greater genes (81455) provided December 12, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued inpatient hospital services from February 4, 2022, 
to February 7, 2022. 
 
You asked the Plan to pay for the inpatient hospital services. You say that this continued admission was 
medically necessary because the enrollee continued with intravenous medication. The Plan denied your request. 
The Plan says it has paid for the admission from January 27, 2022, to February 3, 2022.  The Plan contends that 
inpatient admission after February 3, 2022, was 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 pay for the inpatient hospital services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is a 74 year-old female who was admitted to the hospital on January 27, 
2022, with an 
exacerbation of chronic obstructive pulmonary disease. She additionally had diabetes, hypertension, and 
hyperlipidemia. As of February 2, 2022, she continued to have bilateral wheezing and was receiving 
intravenous steroids with DuoNeb inhalers every 4 hours. On February 4, 2022, she had improved to the point 
where she was switched to oral prednisone while discharge plans were arranged. As of February 4, 2022, she 
was clinically improved and on oral prednisone while discharge planning was arranged. Continued acute care 
stay was not medically necessary from February 4, 2022 to February 7, 2022, as she could have been managed 
at an alternate level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for continued inpatient hospital services from February 4, 2022, to February 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on January 20, 2022. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a separate contract with the 
dialysis facility for payment of these lab services. The Plan denied your request. The Plan says these lab 
services are not separately payable. 
 
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 
lab services provided on January 20, 2022.