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

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that your chances of living longer are 
probably better if you get the LDCT screening. The Plan denied your request. The Plan says the LDCT cannot 
be approved because it is not medically necessary. The Plan also says the records show that you are 78 years 
old. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
 
 We reviewed the file and the Medicare rules. We find that you do not meet the criteria for coverage because 
you are not between the ages of 55 and 77 years old. Therefore, we decided that the Plan does not have to pre-
approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on July 28, 2022. 
 
You asked the Plan to waive the copayment for an injection. You say that the whole procedure only took a few 
minutes anddidnt really even see the provider. 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 $325 
copayment for outpatient hospital services. 
 
You have been asked to pay a $325 copayment for an injection. This item/service falls within the outpatient 
hospital 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 an injection provided 
on July 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 24, 2022, to 
April 22, 2022. 
 
You asked the Plan to pay for the home health services. You say that there is confusion on how to bill the 
claim. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from March 24, 2022, to April 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on July 21, 
2022. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the 
copayment. 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 $10 
copayment for outpatient diagnostic tests/labs.  
 
You have been asked to pay a $10 copayment for laboratory services. This item/service falls within the 
outpatient diagnostic tests/labs 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 
laboratory services provided on July 21, 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 you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of IRF care is correct. 
 
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 clinical documentation does not show that the enrollee would tolerate an intense 
therapy regimen. Therapy notes with poor tolerance and the rehabilitation consultation note states that the "patient was not able to participate in therapy due to frequent stooling." 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need more rides. The Plan 
denied your request. The Plan says your plan benefit for this service for the 2022 plan year is exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-routine transportation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA), nerves innervating the 
sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography) (Bilateral) (64625). 
 
You asked the Plan to pre-approve a RFA. You say that the service is medically necessary. The Plan denied 
your request. The Plan says radiofrequency ablation of the nerves innervating the sacroiliac joint has not been 
proven as effective as standard treatment of SI joint pain. 
 
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 a RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found RFA of the lateral sacral branches is considered experimental because of the wide variation in efficacy 
reported in the literature. 
 
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 RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA), nerves innervating the sacroiliac joint, with image guidance (i.e., 
fluoroscopy or computed tomography) (Bilateral) (64625).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says an LTACH 
admission is not medically necessary, and the enrollee can safely receive the care they need in the current 
hospital setting. 
 
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 that the enrollee is improving and only requires short-term additional acute care at 
the current facility until they are more stable. The enrollee does not require services at the LTACH that are not 
already available at the current facility. 
 
   
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transportation provided on July 23, 2022. 
 
You asked the Plan to pay for ambulance transport. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says this ambulance transportation was a transfer between two skilled 
nursing facilities (SNFs) so is included in the Part A SNF payment and is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF-to-SNF transfers by ambulance are included 
in the consolidated bill paid to the first SNF and are not separately paid as Part B services.  
 
We looked at the file and Medicare rules. This ambulance service is included in the payment to the first SNF 
and is not separately paid by the Plan. Based on this information, we decided that Medicare rules for coverage 
of ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for 
ambulance transportation provided on July 23, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive cardiovascular panel (81401). 
 You asked the Plan to pre-approve a comprehensive cardiovascular panel. You say that the enrollee's condition 
may benefit from this panel. The Plan denied your request. The Plan says under Medicare guidelines, the 
request is not medically necessary because it does not meet the criteria. 
 
{***Add rules/contract recap and to complete decision section. For example: 
 
"The Plan follows Medicare rules. Medicare rules say that the Medicare policy denies coverage for all 
cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or 
documented cardiovascular disease. 
 
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 comprehensive cardiovascular panel. 
Our reviewer says that this service does not meet criteria for coverage. Our physician reviewer found that the 
test is described as a genetic-based cardiovascular risk factor screening test in which multiple genes are 
assessed. It identifies the presence of pathogenic, or likely pathogenic, variants in genes known to be associated 
with increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this enrollees 
clinical management. In summary, the requested testing is not considered 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 a comprehensive cardiovascular panel have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a comprehensive cardiovascular panel (81401).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 14, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint (27280). 
 
You asked the Plan to pre-approve arthrodesis, sacroiliac joint. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the service at issue is 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 pre-approve arthrodesis, sacroiliac joint. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has lumbar degenerative disc disease. There is no sacroiliac 
joint instability, fracture, or lesion. Sacroiliac joint fusion for degenerative low back pain is experimental. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, sacroiliac joint have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, sacroiliac joint (27280).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you need 
this monitor to check your blood sugar level. You also say that you have arthritis and cannot put the monitor in 
the right place to take the sample. The Plan denied your request. The Plan says you do not require insulin three 
or more times daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
  
We looked at the file and Medicare rules. The documentation indicates you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 77066-TC and 76642-TC billed for date of 
service March 15, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. 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.  
 
We find that CPT code 77066-TC was reimbursed by the Plan on March 22, 2022. There is no evidence 
presented to support that the billed items/services were provided twice on the same date. Based on this 
information, we decided that Medicare rules for coverage of the billed services have not been met. 
 
We find that CPT code 76642 was billed with a TC modifier. The total RVUs for codes reported with a TC 
modifier include values for practice expense and malpractice expense only. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 77066-TC and 76642-TC billed for date of service March 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) x3, deep 
sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general anesthesia - each subsequent 15-
minute increment (D9223) x2 and therapeutic parenteral drug, single administration (D9610) provided on 
September 22, 2022. 
 
You asked the Plan to pay for dental services. You say that you were told this would be covered at 50%. If you 
would have known, it was not covered at all you would have asked for names that covered this procedure. The 
Plan denied your request. The Plan says these services are not covered under your Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Extraction, erupted tooth 
requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if 
indicated, deep sedation/general anesthesia - first 15 minutes, deep sedation/general anesthesia - each 
subsequent 15-minute increment and therapeutic parenteral drug, single administration are not covered under 
the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of 
mucoperiosteal flap if indicated (D7210) x3, deep sedation/general anesthesia - first 15 minutes (D9222), deep 
sedation/general anesthesia - each subsequent 15-minute increment (D9223) x2 and therapeutic parenteral drug, 
single administration (D9610) provided on September 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 billed for date of service September 8, 
2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the billed code 
cannot be verified. 
 
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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records do 
not indicate the amount of time spent on discharge management services.  
 Based on this information, we decided that Medicare rules for coverage of the billed services have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99239 billed for date of 
service September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 2, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says an incorrect place 
of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on September 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance and copayment for out-of-network outpatient 
hospital services and an out-of-network office visit provided on March 28, 2022. 
 
You asked the Plan to waive the coinsurance and copayment for out-of-network outpatient hospital services 
and an out-of-network office visit. You say that you disagree with the cost share. 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 20% 
coinsurance for out-of-network outpatient hospital services and a $55 copayment for out-of-network 
physician/practitioner services.  You have been asked to pay a 20% coinsurance for out-of-network outpatient hospital services and a $55 
copayment for an out-of-network office visit. The total allowed amount you are being asked to pay for 
outpatient hospital services is $136.82. You are being asked to pay $68.41 ($136.82 x 50% = $68.41). The total 
amount you are being asked to pay $123.41 ($68.41 + $55 = $123.41). 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 and copayment for out-of-network outpatient hospital services and an out-of-network office visit 
provided on March 28, 2022.