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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 8, 2021. 
 
You asked the Plan to pay for the billed services. You say that clinical evidence supports the testing. The Plan 
denied your request. The Plan says one code must be submitted for the 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 billed services have 
not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services provided on December 7, 2021. 
 
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says the 
services were not urgent or emergent. It was also determined the services rendered could have been provided 
by a participating provider under the members Plan. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for diagnostic radiology services provided on December 7, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from June 15, 2021, to June 
18, 2021. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the enrollee was appropriate for 
inpatient admission due to medically necessary hospitalization spanning 2 midnights. The Plan denied your 
request. The Plan says that the enrollee came to the hospital for feeling weak, did not have a fever, did not have 
an elevated white count, speech therapy was working with enrollee, and there were no other issues. The Plan 
also says the care could have been provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the 
Plan has to pay for the acute inpatient hospital care provided from June 15, 2021, to June 18, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs received on May 2, 2022. 
 
You asked the Plan to pay for the drugs. You say that you are appealing because you don't have that kind of 
money. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs received 
on May 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 27, 
2022, to April 28, 2022. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be 
responsible to pay this. The Plan denied your request. The Plan says the coinsurance has been applied 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 20% 
coinsurance for each in-network Medicare-covered hospital stay each time you are admitted.  
 
You have been asked to pay $1108.29 for an inpatient hospital stay. An inpatient hospital stay falls within the 
Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient 
hospital stay from April 27, 2022, to April 28, 2022.  
 
Date of Service Total Billed Allowed Amount Cost Share 4/27/22 to 4/28/2022 $8170.87 $5541.43 $1108.29
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0656, 
E0667) for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare criteria requires serial leg measurements to confirm persistent leg swelling 
despite conservative treatment. 
 
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 the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that an addendum to a visit note dated 05/31/2022 reports the enrollee "expresses fullness in the 
abdomen" but there are no objective findings from a physical examination are reported showing lymphedema 
of the chest, trunk, or abdomen. As the enrollee has not tried and failed at least four weeks of regular, daily, 
multiple-hour home usage of a basic pump after careful, in-person fitting, training and supervision by a 
technician who is skilled in and who regularly and successfully uses the device, it cannot be said that she has 
unique characteristics that would indicate the segmented pump over a standard pump.  
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0656, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulation, associated manual therapy 
and electrical stimulation. 
 
You asked the Plan to pre-approve chiropractic manipulation, associated manual therapy and electrical 
stimulation. You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic manipulation, associated 
manual therapy and electrical stimulation Our reviewer says that the services are not medically necessary. Our 
physician reviewer found in this case, the record indicates that the enrollee has neck pain and spasm. The 
record provided does not indicate the presence of subluxation documented by physical examination or 
radiographs. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested 
service is not 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 chiropractic manipulation, associated manual therapy and electrical stimulation have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulation, 
associated manual therapy and electrical stimulation.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, at an intensive rehabilitation therapy program. 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 inpatient rehabilitation facility. The enrollee can receive further 
services 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for infusion services provided from January 
17, 2022, to February 25, 2022. 
 
You asked the Plan to waive the copayments for the infusion services. You say that you feel the claims were 
not processed correctly. 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 $335 
copayment for surgery or other services provided at an outpatient hospital. 
 
 
 
 
 
 Date of Service Copayment per EOC Actual Charges 
January 17, 2022 $335 $242.99 
January 24, 2022 $335 $322.50 
February 7, 2022 $335 $242.99 
February 25, 2022 $335 $322.50 
Total:  $1,130.98 
 
You have been asked to pay a total of $1,130.98 for the infusion services, which is less than the $335 
copayment for each service. Since the infusion services were provided at an outpatient hospital, they fall within 
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory 
Surgical Centers 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 copayments for infusion services 
provided from January 17, 2022, to February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram performed on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was medically 
necessary, and you should not be responsible for the copayment. The Plan denied your request. The Plan says 
the copayment was applied 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 $250 
copayment for any diagnostic test or special procedure that is provided in an outpatient department of a hospital 
or ambulatory surgery center or in a hospital operating room, or if it is provided in any setting and a licensed 
staff member monitors your vital signs as you regain sensation after receiving drugs 
to reduce sensation or to minimize discomfort..   
You have been asked to pay $250 for a diagnostic mammogram. A diagnostic mammogram 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 copayment for a diagnostic mammogram performed on February 3, 2022.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services (A0431, A0436) provided on July 13, 2021. 
 
You asked the Plan to pay for air ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that the procedure code/type of bill is inconsistent with the place of 
service. 
 
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 Plans denial rationale indicates that the Type of Bill (TOB) for this claim 
was 0731, which the Plan determined not be a valid TOB for Medicare. Review of the file, however, shows that 
there were two claims submitted to the Plan on different dates, neither of them reporting TOB 0731. One of the 
claims reported TOB 0131 (hospital outpatient) which is valid as this service is considered an outpatient 
institutional service. Since the Plan did not present a valid rationale, we find that the denial of payment is not 
substantiated. Therefore, we decided that the Plan has to pay for air ambulance services (A0431, A0436) 
provided on July 13, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skin substitute treatment, TheraSkin, per square 
centimeter (Q4121). 
 
You asked the Plan to pre-approve TheraSkin. You say that you believe this enrollee will benefit from 
TheraSkin to expedite wound healing. The Plan denied your request. The Plan says that the requested service is 
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 pre-approve TheraSkin. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review indicates that the enrollee has a leg wound. The record sent by the provider indicates 
positive benefit from the present wound care treatments and the wound is healing well. The review indicates 
that the items/services at issue in this case are 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 TheraSkin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skin substitute treatment, TheraSkin, per square centimeter (Q4121).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adhesive bandage (A6413) provided on April 28, 2022. 
 
You asked the Plan to pay for code A6413. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 We find that CPT code A6413 has a status indicator of N on the Physician Fee Schedule. This means that CPT 
code A6413 is not covered. Based on this information, we decided that Medicare rules for coverage of code 
A6413 have not been met. Therefore, we decided that the Plan does not have to pay for the adhesive bandage 
(A6413) provided on April 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the service was medically 
necessary. The Plan denied your request. The Plan says prior authorization was not 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 provider in this case is not a network provider with the Plan. 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 the office visit provided on May 4, 2022, by an out-of-network 
(OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health physical therapy services. 
 
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
 The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
The original request was for 17 home health physical therapy visits. The Plan has agreed to pre-approve 8 
visits. 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 additional services. Our physician 
reviewer found you have a history of diabetes, hypertension, and chronic kidney disease. You underwent 
cervical spine fusion surgery. You do not have a surgical wound at this time. As of September 9, 2022, you 
need assistance with dressing and grooming. Supervision or touching assistance is needed for transfers, 
walking 50 feet with 2 turns, and one step. The clinical documentation does not support that skilled therapy 
services beyond the approved 8 visits are required to provide treatment in order to improve you level of 
function, or to perform a maintenance program to maintain your level of function or prevent deterioration 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional home health physical therapy services.