Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 29, 2021, to 
July 23, 2021. 
 
You asked the Plan to pay for the home health services. You say that the guideline was not explained to you 
properly. You say that it is your understanding that late sending of a RAP will not be cause for non-payment of 
the final claim. You also say that this should be reprocessed. The Plan denied your request. The Plan says an 
exception request was not submitted to waive the 5-day requirement for filing the RAP claim due to a 
circumstance beyond the provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, June 29, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from June 29, 2021, to July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest spine 
(72146) and an MRI of the lumbar spine (72148). 
 
You asked the Plan to pre-approve MRIs of the chest spine and lumbar spine. You say that this is a complex 
patient with high signal in the spinal cord and numbness of the arms and legs with severe Nurofibromatosis. 
You also say that formal physical therapy is not appropriate. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRIs of the chest spine and lumbar 
spine. Our reviewer says that MRIs of the chest spine and lumbar spine are not reasonable and necessary. Our 
physician reviewer found the provided documentation did not clearly show the enrollee has recently tried and 
failed conservative treatment for the symptoms, and there were no signs of a red flag diagnosis to justify 
bypassing this step. Our reviewer found that therefore, this request for the MRIs will be considered not 
medically necessary 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 MRIs of the chest spine and lumbar spine have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the chest spine 
(72146) and an MRI of the lumbar spine (72148).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve portable oxygen concentrator. You say that you need this item. The Plan 
denied your request. The Plan says you already have oxygen equipment that meets your needs and have not 
been evaluated for a portable oxygen concentrator. 
 
The Plan follows Medicare rules. Medicare rules state that a portable oxygen concentrator may be covered if 
certain testing criteria have been met. 
 
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 portable oxygen concentrator. Our 
reviewer says that you do not meet the Medicare criteria for a portable oxygen concentrator. Our physician 
reviewer found you have progressive interstitial lung disease and are currently on home oxygen with a portable 
tank system. You are unable to manage the portable tanks because of weakness. However, there is no testing to 
demonstrate that your blood oxygen level can be maintained greater than 91% using an oxygen conserving 
device and a flow rate of 1 to 4 liters per minute. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the copayment for laboratory services provided on December 30, 2021. 
 
You asked the Plan to waive the copayment for lab services. You say that you were not aware of the 
copayment. The Plan denied your request. The Plan says that the copayment applied is correct. 
 
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 incorrect Evidence of Coverage was submitted. This means that we cannot 
determine the copayment you are being asked to pay is correct or justified by the contract. It is the burden of 
the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so 
we must find in your favor. Therefore, we decided that the Plan has to waive the copayment for laboratory 
services provided on December 30, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service December 
28, 2021. 
  You asked the Plan to pay for procedure code 93042. You say that a provider who prepares a separately 
identifiable interpretation which contributes to the diagnosis of the patient is entitled to payment. You say that 
the denied service should be reprocessed. The Plan denied your request. The Plan says payment for code 93042 
is bundled into payment for code 21310. 
 
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 93042 
is a column II code to column I code 21310. 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 procedure code 93042 billed for date of service December 28, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spine 
for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation of asymmetry of reflex, sensation or motor function. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found that there is mention of 
weakness in the chart, but there are no specific details. There is no x-ray report in the record. The records are 
contradictory. On 7/22/22, the doctor says that the enrollee is trying physical therapy, but later in the records it 
says the enrollee can't do physical therapy because of too much pain. There is no note in the chart from 
physical therapy stating that the enrollee is not a candidate for physical therapy, nor is there any record 
indicating a trial of physical therapy. There is no record of abnormal reflex, loss of bladder control, or any 
other red flags. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lower spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks, bilateral C2-3, C3-4, C4-5. 
 
You asked the Plan to pre-approve medial branch blocks, bilateral C2-3, C3-4, C4-5. You say that medial 
branch blocks, bilateral C2-3, C3-4, C4-5 are medically necessary. The Plan denied your request. The Plan says 
medial branch blocks, bilateral C2-3, C3-4, C4-5 do not meet the Medicare LCD coverage criteria. 
 The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically 
reasonable and necessary when there is pain present for a minimum of 3 months with documented failure to 
respond to noninvasive conservative management (as tolerated). 
 
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 medial branch blocks, bilateral C2-3, 
C3-4, C4-5. Our reviewer says that medial branch blocks, bilateral C2-3, C3-4, C4-5 are not medically 
necessary. Our physician reviewer found that the Medicare criteria is 3 months of conservative therapy. This 
was not met and therefore, the request is deemed medically unreasonable and unnecessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medial branch blocks, bilateral C2-3, C3-4, C4-5 have not been met. Therefore, 
we decided that the Plan does not have to pre-approve medial branch blocks, bilateral C2-3, C3-4, C4-5.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) device (K0554). 
 
You asked the Plan to pre-approve a CGM device. You say that the requested item is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) device (K0554).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the 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 (81455) provided December 12, 
2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this test was 
medically necessary and used to help determine treatment options. The Plan denied your request. The Plan says 
that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making 
in the clinical management of the patient and will be denied automatically as not medically necessary. 
 
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. In this case the Plan denied the targeted genomic sequence analysis panel on the 
basis that it is non-covered by Medicare. Specifically, the Plan stated that Medicare Local Coverage Article: 
Billing and Coding: Molecular Pathology Procedures (A56199) states that genetic testing procedures 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient and will be denied automatically as not medically necessary. We reviewed the article and found 
that this exclusion applies to codes listed in Group 3 in the article. Code 81455 is not listed in Group 3. Thus, 
this exclusion does not apply to the service at issue. Therefore, we decided that the Plan has to pay for the 
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 (81455) provided December 12, 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 pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the procedure will make your life 
better. The Plan denied your request. The Plan says there are no studies demonstrating that the basivertebral 
nerve is the source of your pain. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the Intracept procedure is experimental. More research is needed to show its safety and 
efficacy. Therefore, the request is not considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for outpatient surgery provided on July 13, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you believe this was coded in 
error and this is the wrong amount you owe. The Plan denied your request. The Plan says that the coinsurance 
applied 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 does not say in clear and accurate terms 
disclose when enrollees should expect to pay $0 or 20% coinsurance for outpatient surgery.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for outpatient surgery. The Plan contract does not when enrollees should expect to pay $0 or 20% 
coinsurance for outpatient surgery. This means that the Plan did not follow Medicare rules for disclosure of 
cost sharing information. Therefore, we decided that the Plan has to waive the coinsurance for outpatient 
surgery provided on July 13, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 23, 2022, to March 6, 2022. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled need. 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found that 
based on the medical records provided, there is no documentation that the patient required skilled nursing or 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or 
qualified therapy were not required to safely and effectively provide medically necessary and reasonable 
treatment from 02/23/2022 through 03/06/2022. The records did not document the need for intravenous 
medications, new tube feeding or ostomy care or daily complex wound care or respiratory care. Daily skilled 
services were not required. The patient was walking household distances with a wheeled walker independently 
and was independent for transfers as of 02/22/2022. Services in the nursing facility appear custodial in this case 
from 02/23/2022 through 03/01/2022. The patient was discharged to home on 03/01/2022; thus no skilled care 
was provided 03/01/2022 through 03/06/2022. 
 
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 skilled nursing facility (SNF) services provided to the enrollee from February 23, 2022, to 
March 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on February 
18, 2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not have to pay 
this copayment, as you were unaware of the charge associated with your visit. 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for an urgent care visit. An urgent care visit 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 an urgent 
care visit provided on February 18, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have transportation for 
dialysis treatments. The Plan denied your request. The Plan says as of May 20, 2022, you have used 46 of the 
allowed 48 one-way trips. The Plan also says that this request exceeds the established benefit of 48 one-way 
trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic care provided to the enrollee from January 8, 
2020, to October 14, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says maintenance care is 
not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic care was not medically reasonable and necessary. Our physician reviewer found that the 
record indicates that the enrollee had low back pain. The record provided does not cover the dates in question 
and supports that the treatment received was maintenance 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the chiropractic care provided to the enrollee from January 8, 2020, to October 14, 2020.