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

 
We decided that the Plan does not have to pre-approve insertion of a hypoglossal nerve neurostimulator. 
 
You asked the Plan to pre-approve insertion of a hypoglossal nerve neurostimulator. 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 follows Medicare rules. Medicare rules say that FDA-approved hypoglossal nerve neurostimulation is 
considered medically reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea 
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 pre-approve insertion of a hypoglossal nerve 
neurostimulator. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this case, the record indicates that the enrollee has sleep apnea. The record provided does not contain the 
results of the required Continuous positive airway pressure (CPAP) trial but only a conclusory statement that it 
failed. The record provided does not establish that the coverage criteria of the requested service are satisfied. 
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 insertion of a hypoglossal nerve neurostimulator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve insertion of a hypoglossal nerve neurostimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided from January 31, 2022, to 
March 17, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for acupuncture. The Plan denied your request. The Plan says services were not 
authorized/provided by your primary care physician or by providers within the contracted network. 
 
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 acupuncture services provided from January 31, 
2022, to March 17, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator and portable oxygen provided on 
January 14, 2022 to March 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that the claims were paid in the past. The Plan denied 
your request. The Plan says the services were rendered by an out-of-network provider without prior 
authorization. 
 
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 the oxygen concentrator and portable oxygen 
provided on January 14, 2022 to March 14, 2022 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychotherapy office visit provided on 
March 29, 2022. 
 
You asked the Plan to waive the copayment for a psychotherapy office visit. You say that you do not agree 
with the copayment assessed. The Plan denied your request. The Plan says you have been charged the correct 
copayment 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 $20 
copayment per individual or group visit for outpatient mental health care.  
 
You have been asked to pay a $20 copayment for a psychotherapy office visit. The psychotherapy office visit 
falls within Outpatient Mental Health 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 a psychotherapy office visit provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full hereditary cancer panel coded as 81408, 81407, 
81406, 81405, 81404, 81403, 81321, 81317, 81307, 81298, 81295, 81292, 81201 and 81162 for cancer 
screening provided August 25, 2021. 
 You asked the Plan to pay for the laboratory services. You say that please find the attached documents, review 
and reconsider the claim for payment. The Plan denied your request. The Plan says screening genetic testing is 
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 test at issue in this appeal, the laboratory services, 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 full hereditary cancer panel coded as 81408, 81407, 81406, 81405, 81404, 81403, 81321, 81317, 81307, 
81298, 81295, 81292, 81201 and 81162 for cancer screening provided August 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a laboratory service provided on March 2, 
2022. 
 
You asked the Plan to waive the copayment for a laboratory service. You say that you read the EOC and did 
not see the benefit about lab work. You say that you assumed it would be the same as it was with your other 
Plan. The Plan denied your request. The Plan says you have been charged the correct copayment 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 $10 
copayment per day for other Medicare-covered laboratory tests that are not FIT tests.  
 
You have been asked to pay a $10 copayment for a laboratory service. The laboratory 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 a laboratory service provided on March 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 5, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three (3) office consultation visits and treatment to be 
provided by the requested out-of-network provider. 
 
You asked the Plan to pre-approve three (3) office consultation visits and treatment to be provided by the 
requested out-of-network provider. You say that you do not want to see an in-network neurosurgeon because 
you are nervous of driving on the freeways. The Plan denied your request. The Plan says the Plan will not 
authorize medically necessary care outside the health Plan network unless that care is not available within the 
network. In your case, we have numerous neurosurgeons in your area. 
 
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve three (3) 
office consultation visits and treatment to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 24, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 
the lab services provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a nebulizer, with compressor (E0570) 
provided on April 20, 2020. 
 
You asked the Plan to waive the copayment for the nebulizer, with compressor. You say that the services 
should be covered as you disagree with the charges, were not made aware of them, and they accumulated over 
time. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
provided. 
 
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 Durable Medical Equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the nebulizer, with compressor (allowed is $12.17 x 20% = 
$2.43). Nebulizers, with compressors fall within the Durable Medical Equipment (DME) and related 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 o0bligation 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 nebulizer, with compressor 
(E0570) provided on April 20, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 24, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that you were given wrong laboratory results 
and that's why you ended up going to the ER. The Plan denied your request. The Plan says the copayment 
applied is 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 $90 
copayment per visit to the ER.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall within the Emergency 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 ER visit provided on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 2020. 
 
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 are not covered. 
 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 test at issue in this appeal, a cardiovascular risk assessment panel, 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 laboratory services rendered on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided from September 25, 2019, 
through September 28, 2019, at DRG 330.  You asked the Plan to pay for inpatient services at DRG 330. You say that the medical record is clear regarding 
the documentation of the diagnosis and K56.7 is clinically valid as a secondary diagnosis for this admission. 
You say that DRG 330 is the correct DRG for this admission. The Plan denied your request. The Plan says the 
record does support reporting diagnosis code K56.7. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services with secondary diagnosis code K56.7, defined as ileus 
unspecified. 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 inpatient services at DRG 330. Our 
reviewer says that the documentation does not support secondary diagnosis code K56.7. Our physician 
reviewer found the operating surgeon noted that the enrollee might be experiencing a degree of postoperative 
ileus on the second postoperative day. However, by the third postoperative day, the patient had experienced 
flatus, a bowel movement, was tolerating a diet and was later discharged.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient services provided from September 25, 2019, through September 28, 2019, at DRG 330.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $325 copayment for ambulance transportation provided on 
March 16, 2022. 
 
You asked the Plan to waive the $325 copayment for ambulance transportation. You say that you were not 
aware of the cost share responsibility. The Plan denied your request. The Plan says you must pay a $325 for 
ambulance services. 
 
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 $325 
copayment for Ambulance Services.  
 
You have been asked to pay a $325 copayment for ambulance transportation. Ambulance transportation 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 $325 copayment 
for ambulance transportation provided on March 16, 2022.
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 the items are necessary. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 2, 2022 billed with 
codes 81455, 81301, 81194, and 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not payable as billed. 
 
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 
March 2, 2022 billed with codes 81455, 81301, 81194, and 81479.
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional 
improvement. However, the documentation does not support that you would meet criteria for admission to an 
acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an 
IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain your functional status. In this case, you 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Decipher prostate cancer assay provided on December 
22, 2021. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the test is only covered for those who are at low or very low risk. 
 
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 the enrollee is grade group 5, which makes the enrollee high risk and ineligble for this testng. This can 
be covered, per the National Comprehensive Cancer Network (NCCN), for very-low, low-risk, favorable 
intermediate, and unfavorable intermediate risk prostate cancer in patients with at least ten years life 
expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or 
definitive therapy. 
 
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 the Decipher prostate cancer assay provided on December 22, 2021.