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

 
We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that radiofrequency ablation is medically 
necessary. The Plan denied your request. The Plan says radiofrequency ablation does not meet the Medicare 
LCD 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 radiofrequency ablation. Our reviewer 
says that radiofrequency ablation is not medically necessary. Our physician reviewer found that the pain relief 
from the RFA did not last 6 months as required by the LCD. Therefore, the request is deemed not medically 
reasonable or 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services billed for January 12, 2022. 
 
You asked the Plan to pay for outpatient hospital services. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says this claim was not billed in accordance with 
Medicare regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that value code FD is used when a hospital furnishes an initial placement of a medical device at no 
cost or a reduced cost. 
 
Value code FD was reported on the claim in question. We find that value code FD is not supported in the 
record. Specifically, the item which was provided at reduced cost in this case is a drug and not a device. Based 
on this information, we decided that Medicare rules for coverage of outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services billed for January 
12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Molecular STI/UTI panel (87481, 87491, 87529, 87556) 
provided April 5, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you request reconsideration and payment in 
full for the molecular PCR test performed for the enrollee. The Plan denied your request. The Plan says this 
service is considered experimental and is investigational and 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 looked at the file, and Medicare rules. A review of medical literature and clinical practice guidelines state 
the standard of care for evaluation of urinary tract infection includes a urinalysis, followed by a urine culture 
and susceptibility studies. There is lack of support for the clinical utility of large multiplex PCR urinary tract 
infection panel tests. There is lack of data to suggest these panels alter medical decision making and therefore 
exceeds the enrollee's medical needs.  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 
Molecular STI/UTI panel (87481, 87491, 87529, 87556) provided April 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an emergency room (ER) visit and 
inpatient hospital care provided from September 28, 2021, to October 4, 2021. 
 
You asked the Plan to waive the copayments for the ER visit and inpatient care. You say that you should not 
have to pay for a bill received almost a year later. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
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 each emergency room visit. Copayment is not waived if admitted to the hospital. 
 
Your contract with the Plan also clearly says that you must pay $250 per day for days 1-7 for each inpatient admission. 
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 
benefit category. You have also been asked to pay $250 per day for days 1-6 of inpatient care (no copayment 
for the discharge date). The inpatient care falls within the Inpatient Hospital Care benefit category. The total for 
all services is $1,590 ($250 copayment x 6 days = $1,500 =$90 ER copayment = $1,590). 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 copayments for an emergency room (ER) visit and inpatient hospital care provided 
from September 28, 2021, to October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 15, 2022 billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 0032U, 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that you believe that the treatment sought is 
medically necessary to treat the enrollee based on their medical condition. The Plan denied your request. The 
Plan says the claim does not meet Medicare NCD/LCD criteria. 
 
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 
January 15, 2022 billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81328, 81355, 81335, 0031U, 
0032U, 0033U.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service December 1, 
2021. 
 
You asked the Plan to pay for procedure code 99239. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says the medical records do not support the code billed. 
 
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 99239 is Hospital Discharge Day Management Services; 
more than 30 minutes.  Because this is a timed code, there must be documentation in the medical record 
showing that 31 minutes or more was spent on this service. The medical records do not indicate the number of 
minutes spent on this service, so the code cannot be verified.  The Plan has reached out multiple times to try to 
get documentation from you showing the number of minutes of service for this code billed, but no additional 
information was provided. 
 
Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99239 billed for date of 
service December 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac catheterization. 
 
You asked the Plan to pre-approve cardiac catheterization. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve cardiac catheterization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has not had evidence of a recent change in clinical status. Guidelines do 
not support a need for cardiac catheterization in this setting. As a result, at this time cardiac catheterization 
would not be considered medically appropriate and necessary in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of cardiac catheterization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve cardiac catheterization.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 14, 2021. 
 
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 paid from the dialysis facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 October 14, 2021.
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 member is receiving appropriate in-patient acute care and 
is currently unstable for transfer to an LTACH. 
 
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 currently unstable for transfer and requires additional acute care services that can be administered 
safely at the current facility until more stable and 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 long term acute care hospital (LTACH) services. 
 
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 you are receiving appropriate in-patient acute care and do not 
require transfer to an LTACH. 
 
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. You appear 
to be stable and improving and should only require short-term additional acute care services that can be 
administered safely at the current facility until appropriate for a lower level of care. You do not require services 
at the LTACH that are not already available at the current facility. Our physician reviewer found that your 
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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that your lab does not have a contract with the dialysis 
facility for payment of these lab services. The Plan denied your request. The Plan says these lab services are 
included in the payment to the dialysis facility. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional reimbursement for the health club membership 
(S9970) purchased on July 26, 2021. 
 
You asked the Plan to issue additional reimbursement. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says you did not provide valid proof of 
payment for additional reimbursement for the health club membership purchased. 
 
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.   
 
We reviewed the case file and the Plans rules. Based on this information, we decided that the Plans rules for 
additional coverage of the health club membership purchased have not been met because you have not 
provided valid proof of payment.  The Plan contract states that this benefit includes a wellness allowance for reimbursement up to $150 per 
calendar year towards your cost for membership in a qualified health club or fitness facility. You were initially 
reimbursed $88.50 on April 22, 2022 for the health club membership purchased. However, the additional 
statements submitted to the Plan do not show the year in which the payments were made for this membership. 
Therefore, you have not provided valid proof of payment. Therefore, we decided that the Plan does not have to 
issue additional reimbursement for the health club membership (S9970) purchased on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to be held harmless for the office visit (99214) provided on March 2, 2022. 
 
You asked the Plan to be held harmless for the office visit. You say that these services were medically 
necessary and should be covered by the Plan. The Plan denied your request. The Plan says that Medicare does 
not pay for these services as they were not for any type of disease or injury to the eye. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
These services were performed by a Plan contracted provider. The Plans contracted provider indicated that 
they were medical in nature and not for services excluded from coverage under Medicare. The file does not 
show that the Plan provided notice that the office visit would not be covered. Under Medicare rules, this means 
the office visit is considered approved by the Plan. Therefore, we decided that the Plan has to be held harmless 
for the office visit (99214) provided on March 2, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this device is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
  
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FANCC genetic testing rendered on January 4, 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 that the testing is not covered. 
 
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 Plan references Local Coverage Article (LCA) A53628 in their 
determination; which is not binding for the services at issue and is superseded by National Coverage 
Determination (NCD) 90.2, which allows for coverage of this testing. Therefore, we decided that the Plan has 
to pay for the FANCC genetic testing rendered on January 4, 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: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient services provided from August 23, 2021, to August 25, 
2021. 
 
You asked the Plan to pay for the inpatient services. You say that this was an emergency visit because you 
contracted COVID-19 while you were out of the country visiting family. The Plan denied your request. The 
Plan says that the inpatient services billed did not meet the criteria for emergent or urgently needed services. 
 
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 Plan did not provide a copy of any medical records for this case. Without 
this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. 
Consequently, the Plan has not substantiated their denial of payment. Therefore, we decided that the Plan has to 
pay for the inpatient services provided from August 23, 2021, to August 25, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on January 25, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that the drug testing was medically necessary and ordered 
by the patient's physician. The Plan denied your request. The Plan says this provider is not a network provider 
with the Plan, and the services were not referred by a network provider. The Plan also says that they have also 
determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 drug testing provided on January 25, 2022, by an 
out-of-network (OON) provider.