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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
December 13, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were not seen by a 
physician. The Plan denied your request. The Plan says the copayment applied was 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 $90 
copayment for each covered emergency room visit.  
 
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the Emergency 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 copayment for an 
emergency room visit provided on December 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee is a good candidate for this 
procedure. The Plan denied your request. The Plan says that the members International Prostate Symptom 
Score (IPSS) does not meet the required standards for care. 
 The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation of the prostate for 
treatment for LUTS/BPH treatment can be covered if the enrollees International Prostate Symptom Score 
(IPSS) is greater than or equal to 12. 
 
We looked at the file and Medicare rules. The enrollees IPSS is not greater than or equal to 12. 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 transurethral waterjet ablation of the prostate for the 
enrollee.
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 enrollee needs LTACH care. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to an LTACH. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment in a LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has stabilized medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate. 
 
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 pay for ophthalmological services provided on April 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for ophthalmological services. You say that services provided should be covered 
under the authorization number that the facility received. The Plan denied your request. The Plan says this 
provider is out-of-network with the Plan, and authorization was not obtained prior to the services being 
rendered. 
 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 ophthalmological services provided on April 27, 
2022, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says the requested SNF admission does not meet Medicare 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not document the need for intravenous medications, new tube feeding, 
ostomy care, daily complex wound care or respiratory care. There is no documentation that daily skilled 
services are required. The most recent reports indicate the enrollee is walking household distances with a 
rolling walker with contact guard to minimum assistance and is contact guard assist for transfers, no records 
since 09/07/2022 have been provided. Provided records do not document a significant decline in the enrollees 
functional status to necessitate daily inpatient skilled therapy services. Records do not document that services 
in the home or an assisted living facility with home health care or in a long-term care facility on a part time 
basis are not appropriate in this case. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that the enrollee has a history of prostate cancer 
with radiation, and was recommended to have a repeat in five years. You also say that the enrollee's last 
colonoscopy was on September 26, 2016, and was benign. The Plan denied your request. The Plan says this 
service 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 a colonoscopy. Our reviewer says that 
the requested colonoscopy is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested timeframe for a 6-year colonoscopy rescreening of Appellant does not meet 
medical appropriateness nor necessity criteria, and is not therefore an approved service at this time. 
 
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 colonoscopy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a colonoscopy (45378).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 15, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on February 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Orthovisc (J7324) and the 
arthrocentesis, aspiration and/or injection (20611). 
 
You asked the Plan to pre-approve Hyaluronan or derivative, Orthovisc and the arthrocentesis, aspiration 
and/or injection. The Plan denied your request. The Plan says you have not failed fluid removal (if appropriate) 
or corticosteroid injection. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat series of hyaluronan knee injection(s) for 
patients who have responded to a prior series is considered to be reasonable and necessary under the 
circumstances listed in the Medicare rules section of this letter. 
  
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 Hyaluronan or derivative, Orthovisc 
and the arthrocentesis, aspiration and/or injection. Our reviewer says that the requested service is not 
recommended. Our physician reviewer found the record indicates that you have a history osteoarthritis of the 
knees and now have recurrent pain. The record provided does not indicate that other causes of pain have been 
ruled out. Our reviewer found that the record does not indicate that you have failed conservative 
nonpharmacologic therapy or simple analgesics. Our physician reviewer also found that you were treated with 
viscosupplementation over a year ago, but no standardized assessment of response has been submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hyaluronan or derivative, Orthovisc and the arthrocentesis, aspiration and/or 
injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or 
derivative, Orthovisc (J7324) and the arthrocentesis, aspiration and/or injection (20611).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance service, basic life support, emergency transport provided on 
May 14, 2022. 
 
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the 
ambulance service was medically necessary. The Plan denied your request. The Plan says that there was no 
defined medical emergency, no defined restriction of other methods of transportation. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance service, basic life support, 
emergency transport. Our reviewer says that ambulance service, basic life support, emergency transport was 
medically necessary. Our physician reviewer found that the record indicates that you have Parkinson's disease. 
The record indicates that the medics observed increased focal tremor and you believed that you had a seizure. 
The record indicates that your husband activated 911 when he observed you "writhing." The documentation is 
sufficient to establish that a prudent layperson would believe that without immediate medical attention there 
would be serious jeopardy to his or her health. The elements of the coverage criteria are 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 ambulance service, basic life support, emergency transport have been met. 
Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency transport 
(A0429, A0425) provided on May 14, 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve EndoFLIP 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 that the clinical value and effectiveness of EndoFLIP in the setting 
of dysphagia has not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Medical necessity and 
reasonable criteria are met outside of Plan policy in this unique circumstance for intraoperative performance of 
EndoFlip to assist surgical planning and performance of the POEM procedure which has already been pre-
certified. Our physician reviewer found that the enrollee's condition meets 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 been met. Therefore, we decided that the Plan has to pre-
approve EndoFLIP for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an autoimmune (rheumatoid arthritis), analysis of 12 
biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score 
(81490). 
 
You asked the Plan to pre-approve laboratory service. You say that the enrollee is currently not being treated 
for rheumatoid arthritis due to the history of cancer. She is having some symptoms. You would like to assess 
the degree of inflammation. She had multiple Vectra test in the past and it would be nice to compare. The Plan 
denied your request. The Plan says they cannot approve your gene testing (Vectra DA Blood Test for 
Rheumatoid Arthritis). The Plan knows that the enrollee has been diagnosed with rheumatoid arthritis. There is 
not enough proof that this testing will help her healthcare treatment. 
 
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 laboratory service. 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 occasional pain in the right thumb MCP joint. She has intermittent 
swelling of her fingers; her grip strength is sometimes decreased but overall, she is feeling fine. Office notes of 
07/21/2022 states, symptoms are stable, she currently does not require any treatment and she does not need to 
start any treatment. To assess the degree of inflammation, the provider would like to proceed with Vectra 
testing. The enrollee had a Vectra test done in 2019 and at that time the results were elevated at 58. There is no 
indication that this testing will help the enrollee's healthcare treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laboratory service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, 
utilizing serum, prognostic algorithm reported as a disease activity score (81490).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 24, 2022 billed with 
codes 81162, 81292, 81295, 81298, 81301, 81311, 81317, 81194, & 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 24, 2022 billed with codes 81162, 81292, 81295, 81298, 81301, 81311, 81317, 81194, & 81309.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unlisted molecular pathology procedure (81479) provided on 
September 30, 2021. 
 
You asked the Plan to pay for unlisted molecular pathology procedure. You say that you disagree with the 
denial and have submitted medical records from the provider. The Plan denied your request. The Plan says the 
claim was billed with a date of service inconsistent with Medicare rules governing laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 We find that CPT code 81479 is not supported in the medical record. Specifically, the date of service for the 
laboratory test must be the date the specimen was collected. The records show that the specimen was collected 
on September 9, 2021, and September 16, 2021, and the billed date of service was September 30, 2021. Based 
on this information, we decided that Medicare rules for coverage of unlisted molecular pathology procedure 
have not been met. Therefore, we decided that the Plan does not have to pay for unlisted molecular pathology 
procedure (81479) provided on September 30, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically 
necessary. 
 
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 shows that you require two disciplines of therapy, and you 
have medical comorbidities but there is no documentation to show that you would require close medical 
monitoring on an inpatient basis specialized in rehabilitation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your spouse could not 
drive and administer cpr, so you called the ambulance. The Plan denied your request. The Plan says you were 
charged this cost sharing 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 $305 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $305 for these 
services. 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 the ambulance services.