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

 
We decided that the Plan has to pay for the individual psychotherapy services (90837) provided October 22, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly 
reflect the medical necessity for the services rendered. Please reprocess the claim for payment. The Plan denied 
your request. The Plan says that the service is not supported without required documentation. 
 
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. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for the individual psychotherapy services (90837) provided October 22, 2021.  
 
 
 
 
 
 
 
 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 pay for the office visits and laboratory services provided from April 
20, 2021, through August 30, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says out of state benefits are not included in the enrollee's coverage. 
 
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 the office visits and laboratory services provided 
from April 20, 2021, through August 30, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided by a network 
provider on October 13, 2021. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were not informed 
there would be any cost associated with treatment besides an office visit copayment. The Plan denied your 
request. The Plan says you have been asked to pay 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 20% 
coinsurance per visit for radiation therapy.  
 
You have been asked to pay $347.28 which is 20% of the allowed amount for the radiation therapy. The 
allowed amount is $1,736.42. ($1,736.42 x 20% = $347.28). The radiation therapy 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 coinsurance for radiation therapy provided by a network provider on 
October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 The documentation submitted showed that the laboratory tests reported were related to treatment of ESRD. 
End-stage renal disease was indicated as a reason for the laboratory tests, dialysis occurred on the same date as 
the tests, and a separate professional visit unrelated to ESRD was not indicated in the medical record. 
Therefore, the laboratory tests are included in the dialysis services. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR panel (CPT code(s): 87799 x3, 87798 x11, 
87482, and 87150 x12) provided on November 20, 2021. 
 
You asked the Plan to pay for the services. You say that the services were denied as experimental in error. The 
Plan denied your request. The Plan says the PCR testing is considered unproven and 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 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 indicates that the submitted medical records do not indicate why a reflex culture and 
sensitivity was not performed. The clinical value of PCR panel testing remains unproven in the peer-reviewed 
medical literature. The review indicates that the items/services at issue in this case are not medically reasonable 
or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the urine PCR panel (CPT code(s): 87799 x3, 87798 x11, 87482, and 87150 x12) provided on 
November 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0483) provided on April 
20, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code G0480 (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on April 20, 2021, and received by the lab on April 22, 2021; therefore, the billed code 
cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. 
Therefore, we decided that the Plan does not have to pay for the laboratory service (CPT code G0483) provided 
on April 20, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a 
lower level of care. 
 
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. You 
are medically stable, and you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. There are no acute rehab nursing needs identified or documented in the record. At the current 
functional level, while you may benefit from physical and occupational therapy, you do not need intensive 
therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary 
approach to daily therapy in an IRF. At the current level of function, your rehab can be safely provided at a 
lower intensity and alternate setting. Our physician reviewer found that your 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.
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 the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the documentation does not reveal evidence of 
complex wound care or other skilled nursing SNF need. Your functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter, you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care can be provided in a lower level of care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for cardiac arrest, diabetic ulcer of the foot, and pressure ulcer of buttocks. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound (CPT code 76882) provided on October 6, 
2021. 
 
You asked the Plan to pay for the ultrasound. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered as billed.  
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 76882 
is a column II code to column I code 93971. 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 the ultrasound (CPT code 76882) provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an office visit provided on June 28, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that you have no knowledge of this 
appointment ever happening and feel that this bill is an error. The Plan denied your request. The Plan says that 
the claims were processed correctly and you are being charged the correct amount. 
 
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. the Plan did not provide medical records. Without medical records we cannot 
determine whether or not services took place. Therefore, we decided that the Plan has to waive the copayment 
for an office visit provided on June 28, 2021.  
 
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 placement of Memoderm skin substitute after planned melanoma 
excision. 
 
You asked the Plan to pre-approve the use of Memoderm skin substitute. You say that the wound from the 
melanoma removal will require this as without a graft, the wound cannot be closed. The Plan denied your 
request. The Plan says that this can only be covered if there is no sufficient wound healing after four weeks of 
standard wound care. It cannot be approved for immediately after surgery. 
 
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 use of Memoderm skin substitute. 
Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer 
found the enrollee is to undergo removal of melanoma which will result in a large surgical wound. The 
requested Memoderm is reasonable and necessary to allow for closure of the wound. 
 
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 use of Memoderm skin substitute have been met. Therefore, we decided that 
the Plan has to pre-approve placement of Memoderm skin substitute after planned melanoma excision.  
 
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: Unfavorable

 
We decided that the Plan does not have to pre-approve Udencya (pegfilgrastim-cbqv) treatments. 
 
You asked the Plan to pre-approve the Udencya treatments. You say that it is felt that this should be approved. 
The Plan denied your request. The Plan says step therapy rules require a trial of Zarxio prior to approval of 
Udencya. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Udencya treatments. Our reviewer 
says that the requested drug is not considered medically reasonable and necessary based on step therapy rules. 
Our physician reviewer found the record indicates that the enrollee requires prophylaxis from febrile 
neutropenia in the setting of prostate cancer chemotherapy treatment. The requested medication is a new 
start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one 
alternative, such as Zarxio. The record does not indicate that the enrollee has a contraindication to or would 
have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are 
not satisfied.  
 
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 Udencya treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Udencya (pegfilgrastim-cbqv) treatments.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare part B drugs provided on May 7, 
2021, and May 28, 2021. 
 
You asked the Plan to waive the coinsurance for the Medicare part B drugs. You say that you have been getting 
the same service prior and never been charged a coinsurance. The Plan denied your request. The Plan says the 
proper coinsurance was applied. 
 
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 $3,400 
Maximum out-of-pocket, and a 20% coinsurance for Medicare Part B prescription drugs. Prior to May 7, 2021, 
the total amount paid towards the MOOP was $98.80 leaving a balance of $3,301.20 ($3,400 MOOP - $98.80 
paid towards MOOP). The total amount allowed for the dates of service was $25,585.74 with a total 
coinsurance of $5,117.15 ($25,585.74 total amount allowed x 20% coinsurance). Since the total amount of the 
coinsurance was higher then the MOOP only $3,301.20 was charged as the coinsurance. 
 You have been asked to pay a $3,301.20 coinsurance for Medicare part B drugs. Medicare part B drugs falls 
within the Medicare Part B prescription drugs 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 Medicare part B drugs provided on May 7, 2021, and May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code G0483) provided on June 
7, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. CPT code G0483 (1 
Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the 
specimen was collected on June 7, 2021, and received by the lab on June 9, 2021. It is noted multiple attempts 
were made to obtain additional information from the provider. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (CPT code G0483) provided on June 7, 2021.