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

 
We decided that the Plan does not have to waive the copayment for outpatient therapies provided from 
January 20, 2022, to February 22, 2022. 
 
You asked the Plan to waive the copayment for outpatient therapies. The Plan denied your request. The Plan 
says the cost share was applied correctly per the members benefits.  
 
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 $260 
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers.  
 
You have been asked to pay an allowed amount that is lower than the $260 copayment for outpatient therapies. 
The outpatient therapies falls 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 copayment for outpatient therapies provided from January 20, 
2022, to February 22, 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 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 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 lack of medical complexity and lack of nursing needs and high functional 
mobility status do not support an acute hospital inpatient rehabilitation admission with an interdisciplinary 
approach to rehabilitation care. Documentation does not support the medical necessity for admission to an IRF. 
While the enrollee would benefit from physical and occupation therapy, the enrollee's rehabilitation needs can 
be safely provided 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and will require 
extended acute care. The Plan denied your request. The Plan says based on Medicare guidelines and the 
information we have about the enrollee's condition they do not meet all the requirements. 
 
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. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with acute pneumonia and 
urinary tract infection. The enrollee was treated with mechanical ventilation support, trach and percutaneous 
endoscopic gastrostomy placement, chest tubes, antibiotics, and wound care for chest wound. Recent notes 
describe the enrollee as responding to treatment, tolerating weaning on PS during the day and vent at night with 
plans to continue intravenous antibiotics for another two days, however, the enrollee has hyponatremia and 
need for additional weaning.  
 The enrollee is receiving appropriate care at the present setting. The enrollee does not require services at the 
LTACH that are not available at the current facility where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided 
March 14, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that please see supporting documentation 
attached regarding the medical necessity of the charges. The Plan denied your request. The Plan says services 
do not meet coverage requirements. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There is no provider order for the billed laboratory test. Also, there 
is a more appropriate code to describe the services ordered and provided. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Therefore, we decided 
that the Plan does not have to pay for the unlisted molecular pathology procedure (81479) provided March 14, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy (97161, 97110, 97112, 97140, 97530, 
97035, G0283) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON physical therapy. You say that this office is in a convenient location 
and has more availability for appointments. The Plan denied your request. The Plan says medically necessary 
care is available in-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 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 
physical therapy (97161, 97110, 97112, 97140, 97530, 97035, G0283) to be provided by an out-of-network 
(OON) provider.
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 these orthotics are reasonable and necessary for 
the enrollees foot pain. 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 the enrollee does not suffer from diabetic foot disease and does 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided from June 27, 2021, to June 
28, 2021. 
 
You asked the Plan to pay for the inpatient admission. You say that the services provided were reasonable and 
medically necessary. The Plan denied your request. The Plan says this request is not medically necessary 
because the records show the enrollee did not have a have a condition that required inpatient admission. 
 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 inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show 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 inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided from June 27, 2021, to June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 1, 2022. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this refraction 
was billed with a medical diagnosis. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eye refractions during a routine exam. 
 
We looked at the file and the Plan's rules. The record shows that you received a medical eye exam for the 
diagnosis of Open angle with borderline findings, low risk, bilateral. Based on this information, we decided 
that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye refraction (92015) provided on March 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fluorescent noninfectious agent antibody services coded 
86255 provided on January 31, 2022.  
You asked the Plan to pay for the fluorescent noninfectious agent antibody services. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid.  
 
In this case, the MUE for CPT code 86255 is 5. The MAI value for this code is 3. You billed 19 units of this 
code, exceeding the MUE. The Plan has paid the maximum units of this code (five units). The remaining 14 
units are not payable. Based on this information, we decided that Medicare rules for coverage of the fluorescent 
noninfectious agent antibody services have not been met. Therefore, we decided that the Plan does not have to 
pay for the fluorescent noninfectious agent antibody services coded 86255 provided on January 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on September 30, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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 September 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device 
is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 81455) 
provided on January 18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Targeted genomic 
sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with 
code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and 
will be denied automatically as not medically necessary. Therefore, we decided that the Plan does not have to 
pay for targeted genomic sequence analysis panel (CPT code 81455) provided on January 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99205) with a podiatrist to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that you are not able to find any other providers in 
the network outside of the group that the requested provider is a part of and you are in a lot of pain. The Plan 
denied your request. The Plan says you are seeking to obtain services from a provider that is not in-network, 
and the Plan has several network providers available that can provide the services at issue in this request. 
 
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 
an office visit (99205) with a podiatrist to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing coded 814599 provided on March 17, 
2022. 
 
You asked the Plan to pay for the PrismRA testing. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services rendered are unable to be approved. 
 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. 
 
Review of the file shows that the PrismRA testing is not Food and Drug Administration (FDA) approved. In 
addition, no clinical notes were provided to support the necessity of this testing. This means the PrismRA 
testing at issue in this appeal 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 PrismRA testing 
coded 814599 provided on March 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cardiology genetic panel coded as 81479, 81408, 
81407, 81406, 81405, 81404, 81403 and 81401 provided December 2, 2021. 
 You asked the Plan to pay for the laboratory service. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says screening 
genetic testing 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 test at issue in this appeal, the laboratory service, 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 cardiology genetic panel coded as 81479, 81408, 81407, 81406, 81405, 81404, 81403 and 81401 
provided December 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on December 30, 
2021. 
 
You asked the Plan to pay for the visit. You say that this was billed correctly. The Plan denied your request. 
The Plan says CPT 99213 is bundled into CPT 51705. 
 
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 99213 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and low level of medical decision making. When using time for code selection, 20-29 minutes of 
total time is spent on the date of the encounter." 
 
We asked our coder 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 visit. Our reviewer says that the services at issue in this 
case were not supported by the medical records. Our reviewer found that the services described by code 99213 
are not always performed during the services described by code 51705 (change of bladder tube). However, in 
this case the documentation supports that the office visit was a planned visit for a repeat procedure, that is, the 
exchange of the suprapubic tube. The documentation does not support that a separate and significant service in 
addition to the tube exchange was provided to this enrollee on the date of service.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an office visit provided to the enrollee on December 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychology services by a clinical psychologist (CPT code 
90832) provided on December 30, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Psychotherapy services are covered 
by Medicare under the following conditions: The provider must attempt to consult the attending or primary 
care physician about the services furnished and document the consent or declination date to consultations and 
the date of consultations in the patients medical record. If consultation with the attending or primary care 
physician is unsuccessful, document the patients medical chart with the date and manner of notification to the 
physician. There was no documented contact with the attending/primary care physician. Therefore, we decided 
that the Plan does not have to pay for the psychology services by a clinical psychologist (CPT code 90832) 
provided on December 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Procrit for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the step therapy requirements were not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 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 drug. Our reviewer says that the 
requested drug does not meet the step therapy requirements, and is not medically reasonable or necessary. Our 
physician reviewer found that the plan requires a trial of Epogen or Retacrit before they will approve the 
requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation 
provided indicating that the Plans required drugs would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Procrit for the enrollee.