Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2022. 
 
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 all ESRD-related laboratory services are included in 
the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. 
 
 
 
 
 
 We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-
stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided 
that the Plan does not have to pay for the laboratory services rendered on January 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided February 24, 
2022. 
 
You asked the Plan to pay for the outpatient mental health services. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this type of provider is not eligible for Medicare 
payment. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for psychotherapy services is provided 
when it is performed by Physicians (MD/DO), Clinical psychologists, Clinical Social Workers, Nurse 
practitioners, Clinical Nurse Specialists, and Physician Assistants. Other providers of mental health services 
licensed or otherwise authorized by the state in which they practice may not bill Medicare directly for their 
services. 
 
 
 We looked at the file and Medicare rules. The service was provided by a Marriage and Family Therapist. Based 
on this information, we decided that Medicare rules for coverage of the outpatient mental health services have 
not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services 
provided February 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for the triamcinolone 
acetonide injection, the low osmolar contrast material, and the fluoroscopic guidance for needle placement 
received on June 16, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the triamcinolone acetonide injection, the low 
osmolar contrast material, and the fluoroscopic guidance for needle placement. You say that the provider has billed a completely different amount than the original bill you received. The Plan denied your request. The Plan 
says the claim has been processed correctly per your plan benefits. 
 
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 $160 
copayment for Outpatient Diagnostic Tests.  
 
The total allowed amount for the triamcinolone acetonide injection was $5.16. The 20% coinsurance amount 
owed for this service is $1.03. The total allowed amount for the low osmolar contrast material was $0.64. Your 
20% coinsurance amount owed for this service is $0.13. Your copayment requirement for outpatient diagnostic 
tests is $160. However, the allowed amount for the fluoroscopic guidance for needle placemen was $145.37. 
Since this allowed amount was less than your copayment requirement, you were charged the lesser amount. 
 
You have been asked to pay a $1.03 coinsurance for the triamcinolone acetonide injection, a $0.13 coinsurance 
for the low osmolar contrast material, and a $145.37 copayment for the fluoroscopic guidance for needle 
placement. The triamcinolone acetonide injection falls within the Medicare Part B Drug benefit category, the 
low osmolar contrast material falls within the Surgical Supplies benefit category, and the fluoroscopic guidance 
for needle placement falls within the Outpatient Diagnostic Tests 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 and coinsurance for the triamcinolone acetonide injection, the low osmolar contrast 
material, and the fluoroscopic guidance for needle placement received on June 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for neurophysiology services provided to the enrollee on April 9, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that these codes are inconsistent with the modifier used. 
 
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 
the denied codes is: 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95868: 
 
Needle electromyography; cranial nerve supplied muscles, bilateral 
 
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in the trunk or head 
 
CPT 95938: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in upper and lower limbs 
 
CPT 95939: 
 
Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found that the medical documentation supports 
the use of these codes with the appropriate modifier TC. The information listed on the claim is the proper 
information for a facility claim. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
neurophysiology services provided to the enrollee on April 9, 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 FoundationOne CDx (F1CDx) test (0037U) provided 
February 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the provision of F1CDx to the enrollee 
meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the 
management of the enrollee's advanced cancer. The Plan denied your request. The Plan says does not meet 
Medicare NCD/LCD criteria. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. The next generation sequence testing (NGS) testing panel 
performed included testing for the FANCC gene. Testing for this gene is not a Medicare benefit and is 
statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are 
statutorily excluded service. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
FoundationOne CDx (F1CDx) test (0037U) provided February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on November 16, 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 procedure code 99442 is not supported. 
 
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 99442 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 11-20 minutes of medical discussion. 
 
We find that CPT code 99442 is not supported in the medical record. Specifically, the file shows that the 
provider billed code 99205 (office visit) within 7 days of the telehealth code. 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 telehealth services rendered on November 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented 
skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. The enrollees care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral epidural steroid injection (ESI) services at the L2/L3 
level. 
 
You asked the Plan to pre-approve bilateral epidural steroid injection (ESI) services at the L2/L3 level. You say 
that the requested injection services are medically necessary. You say that the injections provided on April 21 
and May 31, 2022, were diagnostic injections to determine the vertebral level of the pain generator. The Plan 
denied your request. The Plan says that the enrollee has undergone 5 ESI sessions within the rolling 12 months. 
The Plan says that ESIs are limited to a maximum of 4 sessions per spinal region in a 12-month period. 
 
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. Specifically, the Plan has not substantiated their denial reason and properly 
demonstrated that the frequency limitations have been exhausted. Therefore, we decided that the Plan has to 
pre-approve bilateral epidural steroid injection (ESI) services at the L2/L3 level.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an Emergency Room (ER) visit provided 
on January 19, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay the allowed amount of $74.16, which is less than the $90 copayment for an ER 
visit. An ER visit falls within the Emergency Care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an Emergency Room (ER) visit provided on January 19, 2022.  
 Your complaint about being hurt at a store is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stab phlebectomies for removal of varicose veins. 
 
You asked the Plan to pre-approve stab phlebectomies for removal of varicose veins. 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 the treatments for symptomatic varicose tributaries 
are either compressive sclerotherapy or microphlebectomy. 
 
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 stab phlebectomies for removal of 
varicose veins. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee has greater saphenous reflux. The requested procedure is 
excluded by rule in the presence of untreated saphenous reflux. The elements of the coverage rules are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomies for removal of varicose veins have not been met. Therefore, 
we decided that the Plan does not have to pre-approve stab phlebectomies for removal of varicose veins.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 2022. 
 
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 must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. There is no documentation to support that the testing meets the 
Medicare criteria for coverage. 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 laboratory services 
rendered on March 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided from May 7, 2021, 
to May 17, 2021. 
 You asked the Plan to pay for the inpatient mental health services. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says the inpatient mental health admission was not 
medically necessary. The patient was stable at the time of admission with no suicidal or homicidal ideation or 
aggressive or threatening behaviors noted. The patient could have been treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 mental health services. Our 
reviewer says that inpatient mental health services were not medically necessary. Our physician reviewer found 
this 68-year-old male was admitted to the acute inpatient psychiatric hospitalization on May 7, 2021, with 
major neurocognitive disorder, most likely due to vascular illness with behavioral disturbance and vascular 
dementia with paranoia. Based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time as he did not have dangerousness to self or others, and was not showing 
any behavioral issues including aggression. It did not appear medically necessary and reasonable to have 
psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have 
dangerousness to self or others, perceptual disturbance including delusions or aggression. The health plans 
denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient 
mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did 
not appear that active treatment was taking place. It did not appear that the services were reasonably expected 
to improve the patients condition or for the purpose of diagnosis. There was no evidence of an individualized 
treatment plan however the entire record is not present. It did appear that the records were supervised and 
evaluated by a physician. Based upon review the records provided for the admission of this patient does not 
meet criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself 
or others. He is noted to be cooperative and compliant with treatment while not showing any aggressive 
behaviors. 
 
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 mental health services have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient mental health services provided from May 7, 2021, to May 17, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve membership to a specific non-Silver Sneakers facility 
that includes a therapeutic pool. 
 
You asked the Plan to pre-approve the non-Silver Sneakers membership. You say that you need access to a 
therapeutic pool, and none of the Silver Sneakers facilities have this amenity. You are not able to use any other 
exercise equipment due to your condition. You are on a fixed income and state that you could not pay for this 
up front and request reimbursement. You feel that this should be allowed because your doctor has indicated it is 
necessary for you. The Plan denied your request. The Plan says your fitness benefit does not cover membership 
up front for any facility that does not participate in Silver Sneakers. You could elect to obtain these services 
and request reimbursement under your $150 wellness allowance. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only at participating facilities or via reimbursement of fees from a non-participating facility.  
 
 
 Although you may require access to a therapeutic pool, your Plan's benefit does not cover membership for 
facilities that do not participate. The only other option would be to pay up front and request the $150 
reimbursement that is also available under this benefit. The services you are requesting are not covered by 
Medicare or directly through your fitness benefit. Therefore, we decided that the Plan does not have to pre-
approve membership to a specific non-Silver Sneakers facility that includes a therapeutic pool.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on March 2, 2022. 
 
You asked the Plan to pay for the office visit. You say that you called and confirmed that you only had a $20 
copayment. The Plan denied your request. The Plan says this service is not covered by the plan under any 
circumstance. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on March 2, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging (MPI). 
 
You asked the Plan to pre-approve the requested MPI. You say that it is felt that the enrollee needs this imaging 
due to ongoing symptoms and tobacco use. The Plan denied your request. The Plan says the criteria for this 
imaging are not met. 
 
The Plan follows Medicare rules. Medicare rules say that MPI may be covered to evaluate for certain 
conditions when there is a moderate pre-test probability of disease. For those with low pre-test probability of 
disease, MPI is considered reasonable and necessary only if there has been an exercise stress test that is 
inconclusive or presumed to be a false positive.  
 
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 MPI. Our reviewer says 
that the documentation does not support the medical necessity of the requested imaging. Our physician 
reviewer found the patient has a history of dyspnea, lightheadedness, and hypertension. The patients pre-test probability for an abnormal test is low, and there is no documentation that his ECG shows an uninterpretable 
pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, 
there is insufficient documentation to support the medical necessity for the requested cardiac stress testing 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 the requested MPI have not been met. Therefore, we decided that the Plan does 
not have to pre-approve myocardial perfusion imaging (MPI).