Persius/hicric huggingface dataset:
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 enrollee needs inpatient acute rehabilitation for 
physical, occupational, and speech therapies due to decreased mobility, lack of coordination, a history of falls, 
decreased overall strength, and swallowing. The Plan denied your request. The Plan says the IRF care is not 
medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing 
facility (SNF). 
 
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 enrollee is medically stable and does not need a physician's supervision three 
times a week in an IRF. There are no acute rehabilitation nursing needs identified or documented. At the 
current functional level, the enrollee does not need intensive therapies consisting of at least three hours of 
therapy per day at least five days per week with multidisciplinary approach 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan provided 
on July 12, 2022. 
 
You asked the Plan to waive the copayment for computed tomography (CT) scan. You say that you checked 
your book and you should have a $0 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $100 copayment for computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan 
does not have to waive the copayment for computed tomography (CT) scan provided on July 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on May 
14, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were dissatisfied 
with the care at the ER, and had to go back again. 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 $120 
copayment for emergency care. 
 
You have been asked to pay a $120 copayment for an emergency room visit. This item/service 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 May 14, 2022. 
 Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) scan on June 
23, 2022. 
 
You asked the Plan to waive the copayment for CT scan. 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 $150 
copayment for each category of test for each service date. (This copayment does not apply to interpretation 
costs or when these imaging tests are performed on the same day as an emergency room visit or as outpatient 
day surgery.). Covered services include but are not limited to other outpatient diagnostic tests. 
 
 
 
 You have been asked to pay a $150 copayment for CT scan. CT scans fall within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
computed tomography (CT) scan on June 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthotics (L1851 and L2397) provided on May 31, 
2022. 
 
You asked the Plan to pay for the knee orthotics. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not supported. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for the knee orthotics (L1851 and 
L2397) provided on May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oncology (urothelial), mRNA, gene expression profiling 
by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing 
urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided February 25, 2022. 
 You asked the Plan to pay for the laboratory services. You say that you disagree with this decision and request 
prompt review of this information and authorization of coverage for the Cxbladder Detect test for this enrollee. 
The Plan denied your request. The Plan says the services rendered were not authorized. Molecular genetic 
screening testing is not a Medicare benefit when done without documentation of medical indication from the 
treating provider. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. 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 oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes 
(MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for 
having urothelial carcinoma (0012M) provided February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 4, 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 81455 is not supported. 
 
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 81455 is targeted genomic sequence analysis panel, solid 
organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes 
(eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, 
KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), 
interrogation for sequence variants and copy number variants or rearrangements, if performed. 
 
 
 
 
 We find that CPT code 81455 is not supported in the medical record. Specifically, the specimen was not 
collected on the billed date of service. 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 April 4, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
does not require services at the LTACH that are not available at the acute care hospital where she is currently 
receiving care. All medically necessary care is being provided in the current acute care setting. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of 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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is medically necessary for you to 
receive the LTACH services. The Plan denied your request. The Plan says the enrollee does not meet the 
criteria for LTACH admission, and the enrollee can receive the services they need at home with supervision. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting.  
 
  There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The health plan has approved ongoing care in the current acute care 
setting.  
 
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for chemotherapy on May 02, 2022, to May 
31, 2022. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you feel as though the services 
should be covered because it would be half of your income. 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 20% 
coinsurance for Medicare Part B chemotherapy prescription drugs. These drugs are covered under Part B of 
Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include drugs that usually arent self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount 
of $4,911.60 and the allowed is $2,551.20. $2,551.20 x 20% = $510.24. There were 2 visits. $510.24 x 2 = 
$1,020.48. Therefore, results in the total cost sharing amount of $1,020.48.   
 You have been asked to pay a 20% coinsurance for chemotherapy. Chemotherapy 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 
chemotherapy on May 02, 2022, to May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 15, 
2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the date of service for a clinical laboratory test or the technical component of physician 
pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. Medicare rules say that the date of service for clinical laboratory tests 
must be the date that the specimen was collected. 
 
The specimens were collected on February 27, 2020 and February 21, 2022. The billed date of service is March 
15, 2022, which is the date the specimens were tested. The date of service should be when the specimens were 
collected. 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 
on March 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the probing of nasolacrimal duct and an 
injection provided from April 22, 2022, to May 10, 2022. 
 
You asked the Plan to reduce the copayment for the surgical procedures. You say that you went to the hospital 
because an ambulatory surgery center isn't available to you. 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 $325 
copayment for each outpatient surgery at an outpatient hospital facility.  
   
 
You have been asked to pay a $650 copayment for the surgical procedures. The surgical procedures fall within 
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers 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 reduce the copayment for the probing of 
nasolacrimal duct and an injection provided from April 22, 2022, to May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a suction pump, home model, portable or stationary, 
electric, any type, for use with external urine management system (K1006). 
 
You asked the Plan to pre-approve a Purewick external female urine collection device. You say that you would 
like to be approved for the Purewick system due to your limited use of your limbs and frequent UTIs. The Plan 
denied your request. The Plan says Medicare and the Plan do not cover incontinence supplies because they are 
disposable, non-reusable hygiene items and fall outside the scope of coverage. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve a suction pump, home model, 
portable or stationary, electric, any type, for use with external urine management system (K1006).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that it has been 1 year since you had surgery, but 
you still experience episodes of serious pain, including your inner leg. Your doctor suggested feet inserts to 
relieve the burden on your feet. Without the feet inserts, you would have serious pain while standing or 
walking. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot inserts/orthotics (L3020).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Panel testing provided January 22, 2022. 
 
You asked the Plan to pay for the Tempus xT Panel testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA-approved. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT testing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT Panel testing have 
not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Panel testing 
provided January 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on April 07, 
2022. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that you thought insurance 
covered the remaining 20% of the cost after Medicare. 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 $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed 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 the urgent 
care visit provided on April 07, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the duplex scan (ultrasound) of extremity 
veins provided on February 25, 2022. 
 
You asked the Plan to reduce the copayment for the duplex scan (ultrasound) of extremity veins. You say that 
the billed procedure location was incorrect. 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 $100 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service. 
 
You have been asked to pay a $100 copayment for the duplex scan (ultrasound) of extremity veins. This 
item/service falls within the diagnostic procedures and tests, including ultrasounds, at all locations of service 
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 reduce the copayment for the duplex scan (ultrasound) of 
extremity veins provided on February 25, 2022.