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

 
We decided that the Plan does not have to pre-approve four (4) visits for bioimpedance spectroscopy (BIS) 
(93702 x4). 
 
You asked the Plan to pre-approve the visits for BIS. You say that the enrollee is at high risk of developing 
lymphedema, and you believe the use of ImpediMed's L-Dex device is medically necessary. The Plan denied 
your request. The Plan says this request does not meet the criteria for coverage. 
 
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 visits for BIS. Our reviewer says 
that the visits for BIS are not considered medically necessary at this. Our physician reviewer found currently 
available evidence insufficiently supports the general use of this device over standard treatment. Our reviewer 
found that the studies are low number and limited duration and do not show statistically significant reduction in 
lymphedema compared to standard screening methods. Our physician reviewer also found that higher quality 
studies are still needed. 
 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 visits for BIS have not been met. Therefore, we decided that the Plan does 
not have to pre-approve four (4) visits for bioimpedance spectroscopy (BIS) (93702 x4).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 appears to be improving and should only require short-term additional 
acute care services that can safely be completed at the current facility until more appropriate for a lower level 
of care. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer may be considered when treatment has completed. 
 
 
 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet denervation. 
 
You asked the Plan to pre-approve the facet denervation. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section of this 
letter must be met for coverage of this service. 
 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 facet denervation. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the records submitted do not 
support that each MBB provided a minimum of 80% pain relief. 
 
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 facet denervation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet denervation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the hip joint replacement surgery (CPT code 27130) to 
be provided by a provider who opted out of Medicare. 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says federal regulations do not allow payments by the Medicare Advantage Health Plan to a 
provider who has elected to opt to out of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pre-approve the 
hip joint replacement surgery (CPT code 27130) to be provided by a provider who opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on December 11, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were never billed a copayment for 
this procedure. You say that you have this procedure every year and you are unaware of any changes that may 
have occurred with your insurance. 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 $150 
in-network copayment for CT scans.  
 
You have been asked to pay $121, which is less that the standard $150 copayment for a CT scan. The CT scan 
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 CT scan provided on December 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the coronavirus test (87426) provided on 
December 21, 2021, by an out-of-network (OON) provider located out of the country. 
 
You asked the Plan to reimburse you for the coronavirus test. You say that this test was related to travel. You 
also say that it was mandatory in order to take a return flight to the United States. The Plan denied your request. 
The Plan says coronavirus surveillance testing, which is testing used for public health or social purposes such 
as employment (return to workplace), education, travel or entertainment is not a covered benefit. 
 
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 reimburse you 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 reimburse you for these 
items/services. Therefore, we decided that the Plan does not have to reimburse you for the coronavirus test 
(87426) provided on December 21, 2021, by an out-of-network (OON) provider located out of the country.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) sessions. 
 
You asked the Plan to pre-approve additional PT sessions. You say that you are requesting the denial of the 
enrollee's PT be overturned. The Plan denied your request. The Plan says the requested service is not medically 
necessary. 
 
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 additional PT sessions. 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 the additional requested therapy generally is not accepted as 
specific and effective therapy for the patients condition of spinal stenosis and chronic lumbar radiculopathy 
beyond what was approved by the health plan. Our reviewer found that the patient has had prior therapy and 
the documentation does not reveal that the patient requires the unique skills of a professional therapist to safely 
and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, 
or by or under the supervision of a therapist. Our physician reviewer also found that the requested services are 
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is 
not required to establish, design and/or deliver a program to maintain the patient's current condition or to 
prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT sessions have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) sessions.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar spinal surgery, aspiration, and cardiac arrest. The enrollees medical problems are stable. There are no complex 
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has 
a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64495). 
 
You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 The Plan follows Medicare rules. Medicare rules say that the criteria listed in the Medicare Rules section of this 
letter must be met for this service to be 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 facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no documentation that 
the duration of pain has been present for a minimum of 3 months, along with documented failure to respond to 
non-invasive conservative care management (as tolerated). In addition, there is no indication in the provided 
records that the member had had two medically reasonable and necessary diagnostic facet joint procedures with 
each one providing a consistent minimum of 80% relief of primary (index) pain with the duration of relief 
being consistent with the agent used. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64495).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81292, 81317, 81298, 81295). 
 
You asked the Plan to pre-approve the genetic testing. You say that this service is medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***} 
 
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 genetic testing. Our reviewer says 
that the requested genetic testing is not medically necessary. Our physician reviewer found the records 
provided do not demonstrate how the biomarkers will be used for the management or treatment of the patient. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81292, 81317, 81298, 81295).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the materials copay purchased on October 7, 2021. 
 
You asked the Plan to reimburse you for the materials copay. You say that you paid $94 for these eyeglasses on 
the date in question, and the Plan reimbursed you only $69. You would like to be reimbursed for the remaining 
$25. The Plan denied your request. The Plan says that this service is not covered by your vision benefit, and the 
Plan has paid the full/appropriate amount for these eyeglasses. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. The rules also 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. Specifically, there is no documentation to show exactly what was purchased that 
cost $25. The only documentation to support this charge is an itemized receipt which reflects payment and lists 
this item/service as a materials co-pay. However, your contract with the Plan clearly states that you are 
responsible for a $0 copayment for these services up to the $150 benefit maximum each year. There is no 
documentation to show that this benefit maximum was exhausted on the date in question. Based on the 
available records, you have only used $69 of your benefit for 2021. There is also no documentation to support 
that the item or service at issue is not covered by your benefit. 
 
In addition, you were referred for the materials copay item/service by a contract provider. The file does not 
show that the Plan or the contracted provider provided notice that the materials copay would not be covered. 
Under Medicare rules, this means the materials copay is considered approved by the Plan. Therefore, we 
decided that the Plan has to hold you harmless for the materials copay purchased on October 7, 2021. Because 
you have already paid for this service, it is up to the Plan whether they would like to reimburse you directly or 
have the contracted provider issue a refund for this amount. 
 
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: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for practitioner services 
provided on January 25, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for practitioner services. You say that the services 
were not necessary and overpriced. The Plan denied your request. The Plan says the deductible and coinsurance 
amount charged 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 20% 
coinsurance for medically necessary medical or surgical services furnished in a physician's office.  
 
You have been asked to pay a total of $314.92 for practitioner services. $250 was charged towards your 
deductible, then the Plan started to cover their share of the services and you were then charged 20% for the 
remaining services. 
 
Date of Service 
Service 
Provided 
Service 
Code 
Allowed 
Amount 
Cost-Share Per Contract 
Your Cost-
Share 
Responsibility 
January 25, 2022 
Destruction of 
precancer skin 
growth 
17003 $67.90 Deductible $67.90 
January 25, 2022 Biopsy 11103 $257.65 Deductible $182.10 
    
20% coinsurance on 
remaining $75.55 
$15.11 
January 25, 2022 Biopsy 11102 $103.35 20% coinsurance $20.67 
January 25, 2022 office visit 99203 $111.94 20% coinsurance $22.39 
January 25, 2022 
Destruction of 
precancer skin 
growth 
17000 $33.76 20% coinsurance $6.75 
    Total: $314.92 
 
 
Practitioner services fall within the Physician/Practitioner Services, Including Doctors Office Visits 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 deductible and coinsurance for practitioner services provided 
on January 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that both you and 
the prescribing physician are aware the enrollee does not have lymphedema that extends to the truncal area. 
However, the enrollee has suffered from lymphedema for several years. The Plan denied your request. The Plan 
says A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if 
the criteria in this section are met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, a PCD coded as E0652 is not covered for the treatment 
of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be denied as not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for behavioral health services received from October 21, 2021 to 
February 10, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says prior authorization was not obtained for these services, as the physician is not contracted with the 
plan. 
 
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 behavioral health services received from October 
21, 2021 to February 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided to the enrollee on September 20, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 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 44180 
is a column II code to column I code 44207. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for surgical services provided to the enrollee on September 20, 2021.