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

 
We decided that the Plan does not have to waive the copayment for Ambulance services on February 19, 2022. 
 
You asked the Plan to waive the copayment for Ambulance services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 Ambulance services. The total cost share is $1,726.06. 
 
You have been asked to pay a 20% coinsurance for Ambulance services. This item/service falls within the 
Ambulance services 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 Ambulance services 
on February 19, 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 IRF care will help you get back to being more 
independent. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission 
to an IRF. 
 
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 that you are medically stable and do not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or 
acute exacerbations of chronic medical conditions. At your current low functional level, you do not need 3 
hours a day for 5 days a week of therapies with multidisciplinary approach in an IRF. You have no 
rehabilitation nursing needs other than routine nursing care and no medical complexity. While you may benefit 
from physical therapy and occupation therapy, your rehabilitation needs can be safely met in an alternate and 
low intensity setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you have been with this primary 
care physician (PCP) for a long time and would like to retain this provider as your PCP. The Plan denied your 
request. The Plan says there is an in-network provider that can perform the services you need. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Interfyl, 1 mg, (Q4171), arthrocentesis, aspiration 
and/or injection, major joint or bursa without ultrasound guidance (20610x3), arthrocentesis, aspiration and/or 
injection, major joint or bursa with ultrasound guidance, with permanent recording and reporting (20611x3), 
fluoroscopic guidance for needle placement (77002x3) and ultrasonic guidance for needle placement imaging 
supervision and interpretation (76942). 
 
You asked the Plan to pre-approve a special medicine called skin substitutes. You say that the enrollee has tried 
the viscose supplementation which did not help much. She's had steroid infections which helped for brief 
periods. She's undergone physical therapy without real results. The Plan denied your request. The Plan says the 
requested skin and soft tissue substitutes are unproven and not medically necessary for any indication due to 
insufficient evidence of efficacy. 
 
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 a special medicine called skin 
substitutes. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee presented with worsening symptoms. The 
exam of the left knee reveals marked medial joint line tenderness. There is trace effusion. The range of motion 
is 0-110. McMurrays and Apleys are positive. However, there is limited published, large-scale, long-term 
peer-reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. 
Further studies are needed to demonstrate that the use of human connective tissue matrix is as effective as 
treatment in osteoarthritis. Moreover, in this case, there were no diagnostic imaging studies provided to 
corroborate knee pathology that could benefit from such treatment. There is no compelling rationale presented 
or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, 
the requested Interfyl skin substitute, in this case, is 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 a special medicine called skin substitutes have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Interfyl, 1 mg, (Q4171), arthrocentesis, aspiration and/or 
injection, major joint or bursa without ultrasound guidance (20610x3), arthrocentesis, aspiration and/or 
injection, major joint or bursa with ultrasound guidance, with permanent recording and reporting (20611x3), 
fluoroscopic guidance for needle placement (77002x3) and ultrasonic guidance for needle placement imaging 
supervision and interpretation (76942).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cervical, multiple post collar, occipital/mandibular 
supports, adjustable provided to the enrollee on July 14, 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 the documentation submitted did not sufficiently support the billed supply code. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no clear documentation to indicate a need for this neck brace. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for a cervical, multiple post collar, occipital/mandibular supports, adjustable provided to the 
enrollee on July 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the doctor stated you will need a 
feeding tube for 5 days because it needs to be removed. You cannot have it stapled to your throat as it is too 
large and there is no room for more staples. The Plan denied your request. The Plan says the facility confirmed 
that the planned surgery is scheduled as an ambulatory surgery with extended recovery (observation care).  In 
addition, review of the pre-operative office visit notes for this procedure completed by your provider, had no 
findings, treatments, or interventions to indicate that inpatient level of care is required or being ordered. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for acute inpatient hospital care is met in 
this case. Our physician reviewer found removal of esophageal diverticulum procedure was approved but 
inpatient services were requested related to this procedure. Plans for a possible feeding tube were made 
following this procedure, but not definitively decided. Based on this procedure typically being ambulatory and 
you not having high risk factors, or an unstable medical condition based on the provided documentation, this 
request for inpatient status will be considered not medically necessary. Certainly, a request for inpatient 
services might be reasonable following the procedure if clinically appropriate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive hereditary cancer panel provided on May 
23, 2022. 
 
You asked the Plan to pay for the comprehensive hereditary cancer panel. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The comprehensive hereditary cancer panel at issue, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the comprehensive hereditary cancer panel provided on May 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit coded 99214 provided on March 17, 2022. 
 
You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services are not payable 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 99214 is not supported in the medical record. Specifically, Modifier CG 
should be reported with the medical and/or mental health HCPCS code that represents the primary reason for 
the medically necessary face-to-face visit. This service was not billed with the appropriate CG modifier. Based 
on this information, we decided that Medicare rules for coverage of the office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on March 
17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the ventilator is to be used for the treatment of 
post-COVID interstitial lung disease (ILD). The Plan denied your request. The Plan says the request for a home 
mechanical ventilator with settings that could be delivered by BiPAP with AVAPS for this member with post-
COVID interstitial lung disease (ILD) is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 
 
 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 ventilator. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found provided records document the enrollee has 
chronic respiratory failure with hypoxia related to non-specific interstitial pneumonia ("probably a combination 
of rheumatoid lung and post-COVID interstitial lung disease"). Provided records document that the home 
ventilator is being requested for use with very low set volumes (150-200 ml) aimed at assisting respiration 
which could be provided by a BiPAP device with average volume assured pressure support and a back-up rate. 
As stated in the Local Coverage Determination (L33800): "Claims for ventilators used to provide CPAP or bi-
level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and 
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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ramp received on July 29, 2022. 
 
You asked the Plan to pay for the ramp. You say that this ramp was necessary to enable you to go in and out of 
your home using the rollator walker. The Plan denied your request. The Plan says the item received is not a 
covered benefit. 
 
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. 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 pay for the ramp received on July 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services on September 1, 2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says this cost sharing was charged 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 $5 
copayment for laboratory services.  
 
You have been asked to pay a $5 copayment for laboratory services. This item/service 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 laboratory services on September 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional ten (10) chiropractic visits. 
 
You asked the Plan to pre-approve additional chiropractic visits. You say that you need these additional visits 
to treat your pain. The Plan denied your request. The Plan says as there were no baseline or updated measures 
submitted, it is impossible to determine the amount or degree of progress that you have made, so the requested 
number of visits cannot be approved without further documentation as they cannot be deemed 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 additional chiropractic visits. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that you have hip, shoulder, cervical, and lumbar pain. 
The record provided indicates that you have had 11 treatment sessions to date. The medical records do not 
indicate that you have improved with the current treatment. 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 additional chiropractic visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional ten (10) chiropractic visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing provided on May 24, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, we find that the testing described by the billed code is 
considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan does 
not have to pay for the specimen validity testing provided on May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on June 23, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share. The Plan denied your request. The Plan says this cost sharing was charged 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 $35 
copayment for an office visit.  
 
You have been asked to pay a $35 copayment for an office visit. This item/service 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 an office visit on June 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (Q5001, S9123) provided on August 
25, 2021, to August 30, 2021.  
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid 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 Q5001, & S9123 is not supported in the medical record. Specifically, the home health 
claim was not billed with a valid "G" code that appropriately describes the service performed. Based on this 
information, we decided that Medicare rules for coverage of the home health services have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services (Q5001, S9123) provided on 
August 25, 2021, to August 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0481) provided on May 26, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 G0481 is "Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 
drug class(es), including metabolite(s) if performed". 
 We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided do not 
show that 8-14 drug classes were tested on the date of service in question. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services (G0481) provided on May 26, 2022.