Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care provided on August 26, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the wound care. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
 
 
 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for wound care provided on August 26, 2021, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on 
November 16, 2021. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was your yearly 
screening mammogram and was coded as a diagnostic mammogram. You also say that for your recent 
screening, your doctor prescribed a diagnostic test after the initial mammogram screening on November 16, 
2021. 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 $130 
copayment for x-rays, including mammograms taken at any other location other than a physician's office.  
 
The medical record shows you had a diagnostic mammogram at an outpatient hospital on November 16, 2021. 
You have been asked to pay a $130 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on November 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the magnetic resonance imaging (MRI), 
the electromyography, and cystometrogram provided by a network facility on September 30, 2021. 
 
You asked the Plan to waive the copayments for the MRI, the electromyography, and cystometrogram. You say 
that you were billed incorrectly. 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 a $275 
copayment per day, per provider, for in-network Medicare-covered diagnostic radiology services and a $325 
copayment for each in-network Medicare covered outpatient hospital facility visit.  
 
You have been asked to pay a $220.88 copayment for the MRI, which is less than the standard copayment 
amount. You have also been asked to pay a $325 copayment for the electromyography and cystometrogram. 
The MRI falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. 
The electromyography and cystometrogram fall 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 copayments for the MRI, the electromyography, and cystometrogram 
provided by a network facility on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control 
supplies (S8301) provided on September 14, 2021. 
 
You asked the Plan to pay for the IV tubing extension set (S1015) and infection control supplies (S8301). You 
say that the items are provided at your own expense to allow you to perform the procedures with the same level 
of quality and safety as an ambulatory surgical center or hospital. You say that the claim should be reprocessed 
and appropriate payment made. The Plan denied your request. The Plan says the billed codes are not valid for 
Medicare purposes. 
 
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 S1015 is IV tubing extension set. The CPT Code Manual 
definition of code S8301 is infection control supplies, not otherwise specified. 
 
We find that CPT code S1015 and S8301 are not supported in the medical record. Specifically, CPT code 
S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the IV tubing 
extension set (S1015) and infection control supplies (S8301) have not been met. Therefore, we decided that the 
Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) 
provided on September 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the inpatient hospital care and the office 
visit (99204) provided from October 22, 2021, through October 26, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 $295 
copay per day, for days 1-6 for each Medicare-covered inpatient hospital admission. Additionally, you must 
pay a $40 copayment for each Medicare-covered specialist visit.   
  
You have been asked to pay $925 ($885 + $40). This amount includes a $40 copayment for the specialist visit 
provided on October 22, 2021. Additionally, this amount includes a $295 copayment x 3 days= $885 for the 
Medicare-covered inpatient hospital care provided from October 23, 2021, through October 26, 2021. 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 copayments for the inpatient hospital care and the office visit (99204) 
provided from October 22, 2021, through October 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0425, 
A0428) provided on October 24, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says the 
cost-sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Ambulance services.  
 
 You have been asked to pay a $250 copayment for ambulance transportation 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 ambulance transportation services (A0425, A0428) provided on 
October 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from April 7, 2022 
forward. 
 
You asked the Plan to pre-approve the inpatient psychiatric admission. The Plan denied your request. The Plan 
says this request is not medically necessary because the records received show that your condition has 
improved, and you are no longer a threat to yourself or others. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
 
  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 inpatient psychiatric admission. Our 
reviewer says that it does not appear medically necessary and reasonable to have psychiatric care provided at 
the acute inpatient level of care rather than a lower level of care beyond the dates in question. Our physician 
reviewer found it was not expected you would improve in a reasonable period of time beyond the dates in 
question. Our reviewer also found that you do not meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question of April 7, 2022 forward, and could have been treated in a lesser 
restrictive setting, as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations 
and was not showing any aggressive behaviors while being cooperative and compliant. 
 
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 inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission from April 7, 2022 forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (81479) provided 
on September 2, 2021. 
 You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not 
billed with the correct POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 cardiovascular risk assessment testing 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 cardiovascular risk assessment testing (81479) 
provided on September 2, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the GeneSight Psychotropic testing (81479) provided on May 20, 2021. 
 
You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like reconsideration 
because this testing was medically necessary and billed correctly. The Plan denied your request. The Plan says 
that CPT code 81479 is not a valid code per the Physician Fee Schedule. 
 
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 supported in the record. Specifically, it is not appropriate to apply the 
physician fee schedule to laboratory services. CPT code 81479 is the correct CPT code to bill for this testing. 
Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing 
have been met. Therefore, we decided that the Plan has to pay for the GeneSight Psychotropic testing (81479) 
provided on May 20, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the right wrist/hand orthosis (L3916), provided on September 
8, 2021. 
 
You asked the Plan to pay for the right wrist/hand orthosis. You say that the item is medically necessary. The 
Plan denied your request. The Plan says the item 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 pay for the right wrist/hand orthosis. Our reviewer 
says that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not contain an adequate physical examination of the enrollee'e right hand or 
wrist. 
 
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 right wrist/hand orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the right wrist/hand orthosis (L3916), provided on September 8, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable for the enrollee's 
condition. The Plan denied your request. The Plan says rules for SNF care have not been met. 
 
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 member has stabilized medically and is 
ready for discharge from the hospital.  The member does not require skilled nursing and/or skilled therapy 
services on a daily basis.  She is medically stable and can receive further rehab services at a lower level of care.  
Although further rehab services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on April 
28, 2021. 
 You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this test was not 
ordered by the enrollee's physician. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 cardiovascular risk assessment testing 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. 
Additionally, the record suggests that this testing was not ordered by the enrollee's physician and that the 
results did not have an effect on the enrollee's treatment. Therefore, we decided that the Plan does not have to 
pay for the cardiovascular risk assessment testing provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Aduhelm. 
 
You asked the Plan to pre-approve Aduhelm. You say that Aduhelm therapy is likely to reduce amyloid 
plaques, which is likely to delay cognitive disability for the enrollee and enhance health and well-being. The 
Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Aduhelm is 
considered experimental/investigational for all indications. 
 
The Plan must follow Medicare rules. Medicare rules say that use of Aduhelm outside of an approved study is 
nationally non-covered.  
 
We looked at the file and Medicare rules. You say that the enrollee is not currently in any study, nor is 
attempting to enroll in any study, for the diagnosis of Alzheimers disease. Based on this information, we 
decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan 
does not have to pre-approve use of Aduhelm.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission beginning on April 7, 2022. 
 
You asked the Plan to pay for the inpatient hospital admission. The Plan denied your request. The Plan says 
this request is not medically necessary because the records show the enrollee did not require prolonged 
intravenous opioid treatment, their pain was controlled with the initial medication, and their chronic obstructive 
pulmonary disease (COPD) exacerbation improved with initial treatment. The Plan also says that the enrollee's 
baseline COPD was not severe, they had no high-risk acute comorbidity, and they had no altered mental status. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
 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 inpatient hospital admission. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record does not show that at the time of inpatient admission the 
admitting physician reasonably expects that the patient's necessary hospital care would span two midnights. 
 
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 inpatient hospital admission have not been met. Therefore, we decided that 
the Plan does not have to pay for an inpatient hospital admission beginning on April 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Oncology Assay (81206 and 81292) provided 
on July 26, 2021. 
 
You asked the Plan to pay for the Tempus xT Oncology Assay. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage when a 
laboratory assays two or more genes in a patient in parallel. 
 
The Plan must follow Medicare rules. Medicare rules say that correct coding requires that when a panel code is 
ordered, it should be billed, rather than the individual gene codes. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus xT Oncology Assay have not been met. It is not considered correct coding to bill for 
this panel with individual gene codes. Therefore, we decided that the Plan does not have to pay for the Tempus 
xT Oncology Assay (81206 and 81292) provided on July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee requires can safely be received in a different 
setting. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FreeStyle Libre sensor (K0553), provided on December 
7, 2021. 
 
You asked the Plan to pay for the FreeStyle Libre sensor. You say that the item is medically necessary. The 
Plan denied your request. The Plan says insufficient documentation was submitted. 
 
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 a valid proof of delivery, or relevant medical records which support medical 
necessity for the supplies provided in this case. The records show a shipping date of December 3, 2021, and 
delivery date of December 21, 2021, neither of these dates match the date of service. Additionally, the medical 
records submitted do not show this item was medically necessary. 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 FreeStyle Libre sensor (K0553), provided on December 7, 2021.