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

 
We decided that the Plan does not have to pay for the psychotherapy, 30 minutes with patient, (90832) 
provided on March 29, 2022. 
 
You asked the Plan to pay for the mental health service. You say that the service should be covered. The Plan 
denied your request. The Plan says there is no documented contact with the attending or primary care physician 
(PCP). 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the mental health service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy, 30 minutes 
with patient, (90832) provided on March 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share applied for services received on February 24, 
2022. 
 
You asked the Plan to waive the cost share applied for services received. You say that you should only be 
responsible for an office visit copayment. The Plan denied your request. The Plan says this claim was 
processed 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 $45 copayment for an out-of-network specialist 
visit, a $150 copayment for myocardial perfusion imaging, a 20% coinsurance for Medicare Part B drugs, a 
50% coinsurance for out-of-network Durable Medical Equipment, and a $20 copayment for a stress test with 
electrocardiogram. Please note that your contract with the Plan clearly says that you must pay 50% coinsurance 
for out-of-network Durable Medical Equipment. However, you have only been asked to pay $47.20, which is 
less than the 50% coinsurance amount. 
 
You have been asked to pay $309.96 for an office visit, myocardial perfusion imaging, Regadenoson injection, 
Rubidium and stress test with electrocardiogram. An office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. Myocardial perfusion imaging falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. A Regadenoson injection 
falls within the Medicare Part B Prescription Drugs benefit category. Rubidium falls within the Durable 
Medical Equipment (DME) and Related Supplies benefit category. A stress test with electrocardiogram falls 
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the cost share applied for services received on February 24, 2022.  
 
Code Date of Service Billed Amount Allowable Plan Paid Member 
Responsibility 
99212 2/24/2022 $103.00 $55.05 $10.05 $45.00 
78492 2/24/2022 $3106.00 $1527.32 $1377.32 $150.00 
J2785 2/24/2022 $640.00 $238.80 $191.04 $47.76 
A9555 2/24/2022 $236.00 $236.00 $188.80 $47.20 
93015 2/24/2022 $180.00 $69.60 $49.60 $20.00 
Total  $4265.00 $2126.77 $1816.81 $309.96
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a travel power wheelchair. 
 
You asked the Plan to pre-approve a travel power wheelchair. You say that it is necessary to receive a light 
wheelchair for use outside the home traveling. The Plan denied your request. The Plan says the criteria for a 
new power wheelchair have not been met. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. There is no evidence your current device cannot 
be repaired. It appears this lighter wheelchair is being requested specifically for use when you are traveling 
outside of your home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Therefore, we decided that the Plan does not have to pre-approve a travel power 
wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT of the abdomen and pelvis. The Plan denied your request. The Plan 
says this request does not meet criteria for medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT of the abdomen and pelvis. Our 
reviewer says that a CT of the abdomen and pelvis is not reasonable and necessary. Our physician reviewer 
found the review of the records fails to show a valid indication for a CT of the abdomen and pelvis especially 
since the enrollee was last seen in June, had a negative physical exam, and follow up negative complete blood 
count (CBC). Our reviewer also found that, upon being evaluated again to see if symptoms are different or 
there is an abnormal physical exam the request could be revisited. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT of the abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a computed tomography (CT) of the abdomen and pelvis (74177).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage device. 
 
You asked the Plan to pre-approve the massage device. You say that this device is medically necessary. The 
Plan denied your request. The Plan says the requested device is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a massage device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable and should only require short-term additional acute care services that can safely be 
administered 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. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing the denial of long term 
acute care hospital admission. The Plan denied your request. The Plan says based on Medicare guidelines and 
the information we have about your condition you do not meet all the requirements. 
 
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 you were admitted with acute on chronic respiratory failure due to COVID-19 
pneumonia. The record indicates that you are improving but still require acute care services before transitioning 
to a lower level of care. The medical record does not indicate that you require services that you are currently 
receiving but that would not be available at the LTACH 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 the LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
bleeding at the site of G tube. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee could greatly benefit from this treatment. 
The Plan denied your request. The Plan says there is no information showing medication is being administered 
at the provider's office and provided from physician's stock. The Plan also says this is not a buy and bill 
medication, and does not fall under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
 
 
 
 
 
  
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and related services provided on March 29, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit and related services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 did not pre-approve the 
office visit and related services. We found no exception that would require the Plan to pay for the office visit 
and related services. The records provided for review do not show that the services at issue were urgent or 
emergent. Therefore, we decided that the Plan does not have to pay for the office visit and related services 
provided on March 29, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this screening is necessary. The 
Plan denied your request. The Plan says the criteria for coverage of an LDCT scan are not met in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 We reviewed the file and the Medicare rules. We find that the enrollee does not have a tobacco smoking history 
of at least 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose 
computed tomography (LDCT) scan for lung cancer screening.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
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 reviewer says that the 
service is not medically necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs 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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on February 8, 
2022. 
 
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, 
providers should enter the appropriate DEX Z-Code identifier adjacent to the Current Procedural Terminology 
(CPT) code in the comment/narrative field on the claim. 
 
We looked at the file and Medicare rules. A DEX Z-Code identifier was not reported on the claim for this 
Molecular Diagnostic Test service. Based on this information, we decided that Medicare rules for coverage of 
FoundationOne testing have not been met.  
 
 
  
Therefore, we decided that the Plan does not have to pay for FoundationOne testing (0037U) provided on 
February 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
March 4, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these items are not payable as they were 
purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We reviewed the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the hearing aids in this case were purchased from an 
out-of-network provider. The Plan contract says that hearing aids are not covered when rendered by an out-of-
network provider. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing 
aids (V5261) purchased on March 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021, billed with 
codes 81226, 81225, 81231, 81230, 81227 and 81381. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and were billed appropriately. The Plan denied your request. The Plan says these services were not billed in 
accordance with Medicare guidelines. In addition, The Plan argues that this lab is not listed in DEX and 
therefore has not been verified by Palmetto GBA and had an evaluation by the Molecular Diagnostic Services 
(MolDX) Program's technical assessment process. 
 
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 23, 2021, billed with codes 81226, 81225, 81231, 81230, 81227 and 81381.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 3, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. 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 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 February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for back pain and myopathy and was transferred to skilled nursing on 8/8/22. Medical problems 
are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.