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

 
We decided that the Plan does not have to pay for the drug testing services (G0483) provided on November 30, 
2021. 
 
You asked the Plan to pay for the drug testing services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the ordered drug testing 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 the drug testing services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review has determined that the definitive drug testing at issue in this case was not 
medically reasonable and necessary. The review indicates that the diagnosis is medication management of long 
term (current) drug therapy. In this case, the medical records submitted indicate that there was sufficient 
information to manage the member without the definitive testing that was ordered for the member. 
 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 testing services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services (G0483) provided on November 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tradjenta. 
 
You asked the Plan to pre-approve Tradjenta. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says this Medicare Advantage plan does not cover 
outpatient prescription drugs. The Plan says that the enrollee has Verizon, which provides its own pharmacy 
benefits. The Plan says that the enrollee's prescription coverage is provided through Express Scripts. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tradjenta.  
 Benefits for Tradjenta may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive your $45 copayment for a specialist visit on March 7, 2022. 
 
You asked the Plan to waive your $45 copayment for a specialist visit on March 7, 2022. You say that this was 
a follow-up visit for previously received treatment. The Plan denied your request. The Plan says you are 
responsible to pay a $45 copayment for in-network specialist visits. 
 
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 $45 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's 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 your $45 copayment for a specialist visit on March 7, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne CDx (F1CDx) testing provided on January 27, 
2022. 
 
You asked the Plan to pay for the F1CDx panel. You say that this is an FDA-approved test that is covered by 
Medicare. The Plan denied your request. The Plan says that there is a Local Coverage Determination (LCD) 
that indicates that any panel that tests for the FANCC gene is noncovered. Since this panel includes that, the 
denial is correct. 
 
We reviewed the LCD cited by the Plan but find that it is not applicable to an FDA-approved test, as these are 
covered via the NCD cited in the Medicare rules section. An LCD cannot limit coverage allowed by an NCD, 
per the Medicare hierarchy of authority. As such, we disregarded the LCD cited by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, such as the F1CDx panel, when provided for an FDA-approved indication. 
 
We looked at the file and Medicare rules. This testing was provided to a patient with a solid tumor. The FDA 
approval notice indicates that this panel is approved for solid tumors. No other valid denial rationale was 
presented by the Plan. Based on this information, we decided that Medicare rules for coverage of the F1CDx 
testing have been met. Therefore, we decided that the Plan has to pay for the FoundationOne CDx (F1CDx) 
testing provided on January 27, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Zoledronic acid 1MG injection (CPT code J3489). 
 
You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your 
request. The Plan says that there are no notes that show that the enrollee has tried and failed one drug approved 
by their plan (such as a bisphosphonate that the enrollee takes by mouth). The Plan states there are no notes that 
the enrollee had a side effect to an approved drug and there are no notes that the enrollee is unable to take an 
approved drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injection. Our physician reviewer 
found Zoledronic acid is indicated for the treatment and prevention of postmenopausal osteoporosis. This 
diagnosis is supported by the documentation in the case file. The documentation supports that the zoledronic 
acid 1MG injection is safe and effective 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 injection have been met. Therefore, we decided that the Plan has to pre-
approve Zoledronic acid 1MG injection (CPT code J3489).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on January 14, 
2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetic testing is covered when 
specific criteria are met. 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the 
services were not medically necessary.  
 
Our physician reviewer found the enrollee has diagnoses of major depressive disorder and anxiety disorder. 
The provided records only include the assay results and the certificate of medical necessity for the test. The 
records do not include any office visit notes or other clinical documentation indicating necessity of the testing 
as required by Medicare rules. The criteria for coverage are not met and the testing was therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the GeneSight Psychotropic Assay rendered on January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on August 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not 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 August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2021. 
 
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 must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 
81455 are denied as not medically necessary. 
 
We looked at the file and Medicare rules. The services are billed under code 81455. Based on this information, 
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on November 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided April 11, 2022. 
 
You asked the Plan to pay for the orthosis. You say that this claim met all of Medicare's DME LCD coverage 
criteria. The enrollee's primary care provider prescribed this brace within 6 months of the face-to-face visit. 
The Plan denied your request. The Plan says payment is not allowed for this service because a review of the 
claim information showed this service was related to a prohibited 
telemarketing contact. 
 
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone 
regarding the furnishing of a covered item except under specific circumstances. 
 
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an 
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the 
enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated 
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the 
past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have 
not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) 
provided April 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 14, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 84480 is not separately payable. 
 
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 84480 
is a column II code to column I code 84481 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for the laboratory services rendered on January 14, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the add 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says four visits can be approved to finalize a home plan. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 additional visits. Our reviewer says 
that the requested visits are not medically reasonable or necessary. Our physician reviewer found that in this 
case, the documentation doesnt support that you require additional skilled rehab services to provide treatment 
that is medically necessary. You do not require additional skilled rehab services to effectively provide 
treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain 
the members condition and/or prevent deterioration. You have been medically stable without any recent 
exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the add
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia (00880) provided on February 28, 2022. 
 
You asked the Plan to pay for the anesthesia. You say that the enrollee's hospice benefit had been revoked for 
this date of service. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify 
the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the anesthesia (00880) provided on February 28, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the imaging services rendered on January 5, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT codes 77065 and G0279 is 1. The MAI value for this code is 2. You billed 2 
units each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the 
imaging services rendered on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an L3-L5 Lumbar Fusion procedure 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 there is no recent clinical follow-up or exam that supports the need 
for surgical intervention. 
 
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. There is no 
documentation of recent adequate conservative measures for lower back pain treatment. 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 an L3-L5 Lumbar Fusion procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee from October 1, 
2021, to October 29, 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 claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
The records do not show that the correct type of bill was used in this case. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory services provided to the enrollee from October 1, 2021, to October 29, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric services provided on October 6, 2021. 
 
You asked the Plan to pay for psychiatric services. The Plan denied your request. The Plan says the Plan cannot 
determine how the member came to the servicing provider, or whether the services are medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of psychiatric services provided by Community Care Givers, on October 6, 2021 have been met. The file is missing the medical records. 
Therefore, we decided that the Plan does not have to pay for psychiatric services provided on October 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for inpatient psychiatric services on February 
22, 2022, to February 07, 2022. 
 
You asked the Plan to waive the cost-sharing for inpatient psychiatric services. You say that you want to appeal 
the amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being 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 a $650 
copayment per admission for each inpatient stay, Inpatient Hospital and Inpatient Psychiatric Facility. Covered 
services include mental health care services that require a hospital stay.190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit does not apply to Inpatient Mental Health services 
provided in a psychiatric unit of a general hospital. The benefit days used under the Original Medicare program 
will count toward the 190-day lifetime reserve days when enrolling in a Medicare Advantage plan. The total 
charge was $9,716.50 and the Plans discounts is $4,766.50. The claim total is $2,550 and the provider paid 
$1,742.93. Therefore, the $650 copayment + $157.07 deductible results in a total cost-sharing amount of 
$807.07. 
 
You have been asked to pay a $157.07 deductible and a $650 copayment for inpatient psychiatric services. 
Inpatient psychiatric services fall within the Inpatient 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 cost-sharing for inpatient psychiatric services on February 22, 2022, to February 07, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 18, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment 
would be waived if you were in your home county. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 $275 
copayment for each one-way ambulance transport.  
 
You have been asked to pay $224.50, which is less than the $275 copayment for the ambulance transportation. 
Please note that location does not affect the copayment amount. The 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 copayment for ambulance 
transportation provided on November 18, 2021.