Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of speech, language, voice, communication, 
and/or auditory processing disorder (92507) provided on January 7, 2021. 
 
You asked the Plan to pay for the treatment of speech, language, voice, communication, and/or auditory 
processing disorder. You say that the services provided were medically necessary, and you would like this 
claim to be reprocessed for payment. The Plan denied your request. The Plan says this claim was received on 
March 21, 2022, which is past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the treatment of speech, language, voice, communication, and/or auditory 
processing disorder was not filed until March 21, 2022. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for the treatment of speech, language, voice, communication, and/or auditory processing disorder (92507) 
provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a genomic sequence panel provided to the enrollee on 
August 4, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the denial of a targeted genomic sequence panel of 51 or greater genes was appropriate given the 
clinical scenario. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee had metastatic prostate cancer. The denial of testing of 51 or more genes is reasonable. 
The review has determined that the enrollee does not meet the criteria for this testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for a genomic sequence panel provided to the enrollee on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endoscopy services billed with codes 45380 and 45381 for 
date of service November 15, 2021. 
 
You asked the Plan to pay for codes 45380 and 45381. You say that these codes are separately payable. The 
Plan denied your request. The Plan says the payment for these codes is bundled into the payment for 45385. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 
 
 
 
 
 
 
 We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code as 45385, which has been paid. The record indicates that the 
Plan paid the full value of the highest valued endoscopy, plus the difference between the next highest and base 
endoscopy. Therefore, we decided that the Plan does not have to pay for endoscopy services billed with codes 
45380 and 45381 for date of service November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Caris Molecular Intelligence(r) testing rendered on 
January 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of metastatic 
adenocarcinoma of the colon. The requested testing does not have FDA approval or clearance as a companion 
in vitro diagnostic and an Food and Drug Administration (FDA)-approved or -cleared indication for use in the 
enrollee's cancer. The testing was not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the Caris Molecular Intelligence(r) testing rendered on January 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 25, 
2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you should not have to pay this 
copayment. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for physician/practitioner services.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner 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 a 
specialist visit provided on March 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat bilateral transforaminal ESI at the L5 and S1 
levels. 
 
You asked the Plan to pre-approve a repeat bilateral transforaminal ESI at the L5 and S1 levels. You say that a 
repeat bilateral transforaminal ESI is medically necessary. The Plan denied your request. The Plan says a repeat 
bilateral transforaminal ESI 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 a repeat bilateral transforaminal ESI at 
the L5 and S1 levels. Our reviewer says that a repeat bilateral transforaminal ESI at the L5 and S1 levels is not 
medically necessary. Our physician reviewer found that the LCD requirement is for 3 months of pain 
relief. This has not been met and therefore, the request is considered 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 repeat bilateral transforaminal ESI at the L5 and S1 levels have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a repeat bilateral transforaminal ESI at the L5 
and S1 levels.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Botox injection (J0585) and an 
esophagogastroduodenoscopy (43236). 
 
You asked the Plan to pre-approve a Botox injection and an esophagogastroduodenoscopy. You say that the 
requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage have not been met because the requested drug has been prescribed for an off-label and medically 
unsupported use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Botox injection and an 
esophagogastroduodenoscopy. Our reviewer says that the requested treatment is not medically reasonable and 
necessary in this case. Our physician reviewer found that the requested use of Botox is not FDA-approved for 
the enrollees diagnosis of gastroparesis. The use of Botox for gastroparesis is not supported by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
 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 Botox injection have not been met. Furthermore, rules for coverage of an 
esophagogastroduodenoscopy have not been met because this service is intended to deliver an unapproved 
Botox injection. Therefore, we decided that the Plan does not have to pre-approve a Botox injection (J0585) 
and an esophagogastroduodenoscopy (43236).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is necessary for the medical condition 
affecting your feet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for subsequent hospital care provided on 
January 5, 2022. 
 
You asked the Plan to waive the deductible for subsequent hospital care. You say that you want the Plan to 
explain why the provider needs to be paid, because you do not know what the services were. The Plan denied 
your request. The Plan says you were charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $500 deductible for all items and services except those specifically 
excluded by the Plan contract.  
 
 You have been asked to pay $71.44 for subsequent hospital care. Subsequent hospital care falls within the 
benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $500 deductible which applies to inpatient hospital care. This cost sharing is a 
contractual obligation that had not been met at the time subsequent hospital care was received on January 5, 
2022. Therefore, we decided that the Plan does not have to waive the deductible for subsequent hospital care 
provided on January 5, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided 
from May 10, 2021, to June 4, 2021. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are being billed for days you were 
not at the facility. 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 for days 
1-20 a $0 copayment per day and for days 21-100 a $184 copayment per day.  
 
You have been asked to pay $920 ($184 copay x 5 days) for SNF care. The SNF care falls within the Skilled 
Nursing Facility (SNF) 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 skilled 
nursing facility (SNF) care provided from May 10, 2021, to June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment received on February 17, 
2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only for certain indications. 
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case.  
Review of the file shows that while there is a physician order in the case file, there is no itemized receipt for the 
items received. In addition, there is no clinical documentation or any details on the type of bed purchased.  
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the durable medical equipment received on 
February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care from August 13, 2022, to August 17, 2022. 
 You asked the Plan to pay for post-stabilization care. You say that treatment was requested to save your life. 
The Plan denied your request. The Plan says you were stable for transfer to a network hospital at around 
3:00pm on August 12, 2022 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post-stabilization care. Our reviewer says 
that the post-stabilization care was not medically necessary. Our physician reviewer found that the review has 
determined that the there was no specific medical indication for post stabilization care services from August 13, 
2022, forward at the non-Plan facility. The review has determined that the treating physician documents that 
you were stable for transfer. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient care from August 13, 2022, to August 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS system. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee's symptoms have 
worsened. The Plan denied your request. The Plan says the device is considered unproven. 
 
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 requested services. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). There remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CardioMEMS system.
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 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. 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve laser treatment for psoriasis. 
 
You asked the Plan to pre-approve the requested services. You say that the treatments are needed to keep the 
enrollee comfortable. The Plan denied your request. The Plan says that the treatment is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 the requested services. Our physician 
reviewer found that the excimer laser is the standard of care treatment of psoriatic plaques. Therefore, the 
request is considered medically 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve laser treatment for psoriasis.  
 
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 a Minuteman interspinous stabilization device. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
device remains experimental for use. 
 
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 requested services. Our physician 
reviewer found that the Minuteman devices are experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not medically 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caris MI Profile. 
 
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says this 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 the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the record indicates that the enrollee has metastatic adenocarcinoma of the lung. The provided 
record does not document the medical necessity for the requested service for the enrollee at this time. The 
record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Caris MI Profile.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71250 billed for date of service February 15, 
2022. 
 
You asked the Plan to pay for procedure code 71250. You say that this code should be separately paid. The 
Plan denied your request. The Plan says code 71250 is is bundled into payment for code 71260. 
 
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, we have confirmed that code 71250 
is a column II code to column I code 71260 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 71250 billed for date of service February 15, 2022.