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

 
We decided that the Plan does not have to waive the $29.40 coinsurance for home infusion administration on 
April 18, 2022. 
 
You asked the Plan to waive the $29.40 coinsurance for home infusion administration. You say that you would 
like the $29.40 coinsurance waived due to financial hardship. The Plan denied your request. The Plan says you 
are responsible to pay $29.40. 
 
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 Home Infusion Therapy.  
 
 
 
 
 
 
 You have been asked to pay a $29.40 coinsurance for home infusion administration. Home infusion 
administration falls within the Home Infusion Therapy 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 $29.40 coinsurance for home infusion administration on April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 6, 2021, billed with 
codes 81206, 81235, and 81321. 
 
You asked the Plan to pay for the genetic testing billed. 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 covered 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 
June 6, 2021, billed with codes 81206, 81235, and 81321.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 19, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
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. The panel was billed with multiple codes on multiple claims. Based on this information, we 
decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the genetic testing provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided from August 30, 2021, 
to September 1, 2021. 
 
You asked the Plan to pay for hospital services. You say that this claim was billed correctly, and these services 
are supported in the records. The Plan denied your request. The Plan says this claim has one or more Integrated 
Outpatient Code Editor (I/OCE) edit errors, and this claim cannot be paid until this information is corrected. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS code G0378 may only be reported once 
on OPPS bill type 13x claims or non-OPPS bill type 85x claims. If code G0378 is reported more than once per 
claim, then edit 51 is applied and the claim is returned to the provider for correction. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hospital services have not been met. Specifically, G0378 is reported twice on this claim. Therefore, 
OCE edit 51 applies and this claim is rejected to be returned to the provider for correction. Therefore, we 
decided that the Plan does not have to pay for outpatient hospital services provided from August 30, 2021, to 
September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 17, 2021, billed with 
codes 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81355, 81479, 81226, 81231, 81232, 81306, 81328, 
81238 and 81335. 
 
You asked the Plan to pay for the genetic testing billed. The Plan denied your request. The Plan says the 
services were billed incorrectly. 
 
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 
May 17, 2021, billed with codes 81220, 81225, 81227, 81230, 81240, 81241, 81291, 81355, 81479, 81226, 
81231, 81232, 81306, 81328, 81238 and 81335.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Procalcitonin test (84145) provided November 18, 2021 to December 
14, 2021 
 
You asked the Plan to pay for the laboratory services. You say that please see attached letter of medical 
necessity. The Plan denied your request. The Plan says that prior authorization was not received for these 
services and the lab tests are not medically necessary under Medicare coverage criteria. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider and the servicing lab is also a contract 
provider. The file does not show that the Plan provided notice that the laboratory services would not be 
covered. Under Medicare rules, this means the laboratory services is considered approved by the Plan. 
Therefore, we decided that the Plan has to pay for Procalcitonin test (84145) provided November 18, 2021 to 
December 14, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are 
receiving appropriate inpatient care at the current hospital. 
 
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 already 
available at the current facility. Completion of treatment at the current facility is recommended 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
March 9, 2022. 
 
You asked the Plan to waive the copayment for the EKG. You say that this service should be included with 
your $35 copayment. 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 $20 
copayment for non-radiological diagnostic services, including EKGs.  
 
You have been asked to pay $12.37, which is less than the $20 copayment for the EKG. The EKG 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 an electrocardiogram (EKG) provided on March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 10, 2022. 
 
You asked the Plan to pay for the laboratory services. 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 covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the laboratory services provided on January 10, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve positron emission tomography (PET) imaging with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-
thigh. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 services. Our reviewer says that the 
requested services are medically reasonable or necessary. Our physician reviewer found that the National 
Comprehensive Cancer Network (NCCN) guidelines have recently been modified such that prostate-specific 
membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) is recommended 
in patients with very high risk prostate cancer such as this patient. Such a test is the single best imaging exam 
to determine the appropriate targeting of tumor when radiation therapy is contemplated. The enrollee has had a 
negative Technetium bone scan, which is reassuring; however, bone metastases are not completely ruled out. 
The location of the tumor within the gland is such that local or regional lymph node involvement would need to 
be ruled out prior to definitive radiation targeted therapy. This approach has been recently advocated by many 
urologists and is standard practice for this particular scenario. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve positron emission tomography (PET) imaging with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization; skull base to mid-thigh.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) provided December 29, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing panels that include the FANCC 
gene are non-covered. 
 
We looked at the file and Medicare rules. The test preformed is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that 
the Plan does not have to pay for genetic testing (0037U) provided December 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found that based on 
the medical records provided there is no documentation that the patient requires skilled nursing services or 
skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or 
qualified therapist are not required to safely and effectively provide medically necessary and reasonable 
treatment. The records do not document the need for intravenous medications, new tube feeding or ostomy care 
or daily complex wound care or respiratory care. Therapy services have been discontinued and 24 hour 
supervision has been recommended for his ongoing care. The enrollee is walking household distances without 
an assistive device with stand by assistance and is stand by assist for transfers. Provided records do not 
document a significant decline in the patients functional status compared to his recent baseline to necessitate 
daily inpatient skilled therapy services. There is no documentation that the patient requires the services on an 
inpatient basis, only in a skilled nursing facility setting. Records do not document that services in the home 
with home health care or in a long-term care facility on a part time basis (if needed) 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epogen. 
 
You asked the Plan to pre-approve Epogen. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Epogen. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the case file does not contain 
documentation of trial and failure of Retacrit or Procrit. The documentation does not support that Retacrit or 
Procrit would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Epogen have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Epogen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided from January 13, 2022, to January 
21, 2022. 
 
You asked the Plan to pay for hospital services. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim was not billed with a valid clinical trial number. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report a valid clinical trial number on claims for items/services provided in clinical 
trials/studies/registries, or under CED. 
 
 
 We find that that Medicare rules for payment of these hospital services have not been met. Specifically, this 
claim was billed with an invalid clinical trial number. Therefore, we decided that the Plan does not have to pay 
for hospital services provided from January 13, 2022, to January 21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) 
provided November 25, 2021. 
 
You asked the Plan to pay for the ambulance response. You say that the enrollee required emergency help but 
did not require transport to the hospital. The Plan denied your request. The Plan says this service is not covered 
when there is no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 25, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no 
transport (A0998) provided November 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99231) provided from  
January 21, 2022, through January 25, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services at issue are not payable as the 
medical records provided do not match the dates of service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the subsequent hospital care (99231) 
provided from January 21, 2022, through January 25, 2022 have been met. Specifically, the medical records 
provided do not match the dates of service billed in this case. Therefore, we decided that the Plan does not have 
to pay for the subsequent hospital care (99231) provided from January 21, 2022, through January 25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthodontic procedure (41899). 
 
You asked the Plan to pre-approve the orthodontic procedure. You say that this service is medically necessary. 
The Plan denied your request. The Plan says the recommended procedure is orthodontic in nature and is not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an 
orthodontic procedure (41899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99204) provided December 10, 2021. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
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 99204 is outpatient visit for the evaluation and 
management of a new patient. 
 
 
 
 
 
 
 
 We find that CPT code 99204 is not supported in the medical record. Specifically, the record does not show 
that the enrollee is a new patient to this provider. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
office visit (99204) provided December 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98942) to be 
rendered by the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render the 
requested service. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve chiropractic 
manipulative treatment (98942) to be rendered by the out-of-network (OON) provider.