Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) provided on December 14, 2021. 
 
You asked the Plan to pay for the psychotherapy service. You say that the service should be covered. The Plan 
denied your request. The Plan says there was no documented contact with the enrollee's attending or primary 
care physician. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy service have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) 
provided on December 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injections on June 27, 2022. 
 
You asked the Plan to waive the copayment for injections. You say that you want to appeal the amount being 
charged. 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 $300 
copayment per visit at an ambulatory surgical center. If you are having surgery in a hospital facility, you should 
check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an 
order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for 
outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. 
The provider billed in the amount of $303 and the allowed amount is $281.25. This is less than the copayment 
amount. Therefore, results in the total cost sharing amount of $281.25. 
 
 
 
 You have been asked to pay a $281.25 copayment, which is less than the copayment for injections. This 
item/service falls within the Outpatient surgery, including 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 injections 
on June 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on November 29, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the tests are not 
a Medicare benefit when done without a medical indication. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 83036 and 82607 is not supported in the medical record. Specifically, there are 
insufficient medical records to show that the testing was ordered for a specific medical problem. Based on this 
information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, 
we decided that the Plan does not have to pay for the lab testing services provided on November 29, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued SNF services after November 11, 2022. 
 
You asked the Plan to pre-approve continued SNF care. You say that the enrollee is weak and their ability to 
function has deteriorated. You say that the enrollee risks further injury from falling and is not able to go home 
at this time due to the condition they are in. The Plan denied your request. The Plan says that approval of 
continued admission in the SNF does not meet the requirements for approval. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before November 11, 2022. Specifically, the NOMNC submitted in the case file is not signed to 
support the enrollee or representative was properly notified. The Plan must pay for SNF services until the 100-
day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. 
Therefore, we decided that the Plan has to pre-approve continued SNF services after November 11, 2022.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that BiPAP or continuous positive airway 
pressure (CPAP) will not meet the enrollee's complex needs. Without the requested device, the enrollee is at 
increased risk of hospital readmission. The enrollee lives in a rural area where he cannot get appropriate care if 
he has a respiratory emergency. The Plan denied your request. The Plan says the request is not medically 
necessary because the records do not show that the enrollee has failed a BiPAP or CPAP device treating 
breathing issues. 
 
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 home ventilator. Our reviewer says 
that a home ventilator is not medically necessary. Our physician reviewer found this patient has chronic obstructive pulmonary disease and cardiomyopathy.  During a recent hospitalization, arterial blood gas (ABG) 
was consistent with acute on chronic CO2 retention.  There is no ABG done while stable as an outpatient.  If 
the patient does have chronic CO2 retention, they may benefit from bi-level positive airway pressure (BiPAP) 
with average volume-assisted pressure support (AVAPS) during sleep.  However, Medicare does not cover a 
home ventilator when used as BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get mobility to be able to go home. The 
Plan denied your request. The Plan says the IRF services you are requesting do not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. The rules say that an 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 documentation shows that you have functional impairments but there are no 
complex functional deficits, and intense therapy or interdisciplinary team management in an IRF setting would 
not be required. Clinical documentation states that your medical problems are stable and there are no conditions 
that would be expected to require close medical supervision on an inpatient basis during rehabilitation. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (cutaneous squamous cell carcinoma), mRNA 
gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed 
paraffin embedded tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B) 
(0315U) provided May 3, 2022. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that your claim for the DecisionDx-SCC test 
was denied in error and you are requesting to be reprocessed and paid. The DecisionDx-SCC test is a covered 
Medicare benefit. The Plan denied your request. The Plan says scientific research has not established the long-
term effectiveness and improvement on outcomes in cutaneous squamous cell cancer. This test has not been 
cleared or approved by the FDA. 
 
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 DecisionDx-SCC test. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the DecisionDx-SCC is a genomic test that was developed to predict metastatic risk 
for SCC patients with one or more risk factors. The test classifies patients as low (Class 1), moderate (Class 
2A) or high (Class 2B) biological risk of metastasis. DecisionDx-SCC demonstrates a high degree of analytical 
precision, yielding high concordance rates across multiple performance experiments, along with exhibiting 
robust technical reliability on clinical samples. Literature search has not established its long-term effectiveness 
and improvement on outcomes in cutaneous squamous cell cancer. The test has not been cleared or approved 
by the FDA. The review has determined that the medical records provided did not meet the medically 
necessary requirements listed in the LCD for Medicare coverage. 
 
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 DecisionDx-SCC test have not been met. Therefore, we decided that the 
Plan does not have to pay for Oncology (cutaneous squamous cell carcinoma), mRNA gene expression 
profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin embedded 
tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B) (0315U) provided May 3, 
2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy sessions provided by a 
participating provider. 
 
You asked the Plan to pre-approve physical therapy. You say that additional PT is medically necessary. The 
Plan denied your request. The Plan says these services have been correct denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
  
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided, the requested therapy 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy sessions provided by a participating provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says a SNF admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, you do not qualify for SNF coverage. You do 
not have documented skilled nursing needs. Your colostomy is established. You do not have documented 
skilled therapy needs. You appear to be functioning at your baseline. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are 
custodial and can, as a practical matter, be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for television and telephone services provided during inpatient 
hospital care provided from June 16, 2022, to June 28, 2022. 
 
You asked the Plan to pay for television and telephone services. You say that television and telephone services 
should be paid by the Plan. The Plan denied your request. The Plan says Medicare does not cover television 
and telephone services as part of inpatient hospital care. 
 
The Plan must follow Medicare rules. The rules say charges for special items requested by the patient such as 
radio, television, telephone, and air conditioner, and beauty and barber services are excluded from coverage. 
 
We looked at the file, the Plans rules and Medicare rules. Medicare says charges for special items requested by 
the patient such as radio, television, telephone, and air conditioner, and beauty and barber services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for television and telephone services 
provided during inpatient hospital care provided from June 16, 2022, to June 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an ambulatory continuous glucose monitor 
reading (95251) provided on May 25, 2022. 
 
You asked the Plan to waive the coinsurance for a continuous glucose monitor. You say that you do not recall 
going into the office on the date of service in question. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. The Plan says that glucose monitoring supplies are only paid for when obtained 
at an in-network pharmacy. You received services from a durable medical equipment provider, not a pharmacy. 
Therefore, you are responsible for the applicable cost share for DME. 
 
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 a continuous glucose monitor. This item/service falls 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 obligation you agreed to pay when you enrolled in the Plan.  Therefore, we 
decided that the Plan does not have to waive the coinsurance for an ambulatory continuous glucose monitor 
reading (95251) provided on May 25, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the hospital discharge day management services coded 99239 provided 
on February 20, 2022. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that payment is 
not made for a subsequent hospital visit in addition to a hospital discharge day management service on the 
same day by the same physician. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has denied payment for code 99239 because there was 
previously payment made for subsequent hospital care coded 99232 by the same physician on the same day. 
However, the Plan has not provided proof that payment was made for this code as billed. Therefore, we decided 
that the Plan has to pay for the hospital discharge day management services coded 99239 provided on February 
20, 2022.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a vascular ablation procedure (36482). 
 
You asked the Plan to pre-approve the procedure. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that the requested procedure 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 procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has already undergone a similar procedure on the left side with satisfactory results. The 
enrollee is having significant symptoms on the right with evidence of reflux in the proximal right great 
saphenous vein. The procedure in question is FDA approved, is not experimental, and has established 
procedure codes that are associated with the patients diagnosis. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve a vascular ablation procedure (36482).  
 
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 pay for a diagnostic lumbar puncture (62328) provided on May 12, 
2022. 
 
You asked the Plan to pay for a diagnostic lumbar puncture. You say that the service at issue was a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the service at issue was 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 pay for a diagnostic lumbar puncture. Our reviewer 
says that the service at issue is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the case record lacks medical documentation by the physician to support medical 
necessity. The documentation submitted is the procedure note, but there is no prior clinical documentation or referral notating the enrollee's symptoms and the assessment of optic neuritis that led to the plan for a 
diagnostic lumbar puncture. 
 
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 diagnostic lumbar puncture have not been met. Therefore, we decided that the 
Plan does not have to pay for a diagnostic lumbar puncture (62328) provided on May 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for routine blood work provided on July 6, 
2022. 
 
You asked the Plan to waive the copayment for routine blood work. You say that this is a routine blood work 
and should be covered at 100%. 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 $50 
copayment for laboratory services.  
 
You have been asked to pay $14.02, which is less than the $50 copayment for routine blood work. This 
item/service falls within the laboratory 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 routine blood work provided on July 6, 2022.