Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is medically stable, and the records do not show a need for an intensive 
program with a team of health care professionals and doctors that specialize in complex medical needs as well 
as rehab. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of stroke in October 2021 and is living at home with ongoing weakness after 
completing a course of care in skilled nursing facility and a course of home health physical therapy. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health services (90791) 
provided from August 24, 2021, to December 6, 2021. 
 
You asked the Plan to waive the copayment for the outpatient mental health services. You say that the services 
should be covered as you were unaware that they could be cheaper if performed through MDLive. 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 $40 
copayment for Outpatient mental health care.  
 
 You have been asked to pay a $600 copayment for 15 outpatient mental health visits ($40 x 15 = $600). 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 outpatient mental health services (90791) provided from 
August 24, 2021, to December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for therapeutic radiology (77470, 77290, 
77263) services provided on October 7, 2021. 
 
You asked the Plan to waive the coinsurance for the therapeutic radiology services. You say that the services 
should be covered. 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 20% 
coinsurance for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a 20% coinsurance for therapeutic radiology services (allowed is $776.76 x 20% = 
$155.36). Therapeutic radiology services 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 coinsurance for therapeutic radiology 
(77470, 77290, 77263) services provided on October 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided July 
14, 2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because 
the services proved were medically necessary and meet all applicable professionally recognized standards of 
healthcare. The Plan denied your request. The Plan says the services are not supported without the required 
documentation.  
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy 
services (90834) provided July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography cerebral perfusion analysis (CTP) 
provided on October 17, 2021. 
 
You asked the Plan to pay for CTP. You say that this service was medically necessary. The Plan denied your 
request. The Plan says this service did not meet local coverage determination (LCD) coverage criteria.  
The Plan must follow Medicare rules. Medicare rules say that CTP is only covered for patients with small acute 
ischemic stroke caused by unilateral large vessel occlusion.  The records you provided state that this test was 
performed due to dysphagia and left-sided weakness.  The outcome of this service stated that there was no 
evidence of acute infarction or intracranial hemorrhage.  There is no evidence of ischemic stroke noted in the 
medical record.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CTP have not been met. Therefore, we decided that the Plan does not have to pay for computed 
tomography cerebral perfusion analysis (CTP) provided on October 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 1, 2021. 
 
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 the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan with 
concurrently acquired computed tomography (CT) scan from skull base to mid-thigh (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. You say that it is medically necessary for the enrollee to 
receive the imaging service. The Plan denied your request. The Plan says the criteria for a PET/CT scan have 
not been met. 
 
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 a PET/CT scan. Our reviewer says that 
the requested imaging service is not medically reasonable and necessary. Our physician reviewer found there is 
no CT chest report in the records but a CT calcium scoring study is compared to a CT of January 30, 2020.  It 
is not clear if this CT chest is the one reviewed by the pulmonologist with the patient.  Results of surveillance 
CT done recently are not evident.  There is no cytological or imaging evidence of change to suggest 
malignancy and since there is no tissue diagnosis of malignancy nor growing pulmonary nodule there is no medical necessity documented for PET/CT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed 
tomography (CT) scan from skull base to mid-thigh (78815).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you would like to get a second 
opinion consultation, so you can explore all of your options to treat your stage 4 aggressive tumor in your head. 
The Plan denied your request. The Plan says there are providers in-network that can render the services. 
 
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-
approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the second 
opinion to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator (E1390) provided 
on October 18, 2021. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that the services should be 
covered. The Plan denied your request. The Plan says the coinsurance 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 20% 
coinsurance for Durable Medical Equipment (DME) and Related Supplies.  
 
 
  You have been asked to pay a 20% coinsurance for an oxygen concentrator (allowed is $75.61 x 20% = 
$15.12). Oxygen concentrators fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for an oxygen concentrator (E1390) provided on 
October 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging (78452) 
and the transthoracic echocardiography (93306) provided on September 30, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has 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 20% coinsurance for Medicare-covered 
radiological diagnostic services, not including x-rays, when performed in a hospital, outpatient facility, or a 
free-standing facility imaging or diagnostic center. Additionally, you must pay a $35 copayment for Medicare-
covered radiological diagnostic services, not including x-rays, when performed in the doctors office.    
 
You have been asked to pay $342.89 ($250.33 +$92.56). This includes the Plan allowed amount of  
($1,276.67 x 20% coinsurance= $250.33) for the myocardial perfusion imaging and the Plan allowed amount of  
($472.07 x 20% coinsurance=$92.56) for the ultrasound exam provided at an outpatient hospital facility. These 
amounts are less than the applicable coinsurance for the services provided in this case. 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 the myocardial perfusion imaging (78452) and the transthoracic 
echocardiography (93306) provided on September 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies (CPT code(s): K0553 and 
K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies are medically 
necessary, and they are out of medication. The Plan denied your request. The Plan says the Medicare rules 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 shows the enrollee injects insulin only once or 
twice per day and do not use an insulin pump. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the CGM and supplies (CPT code(s): K0553 and K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass lens enhancements provided on  
November 17, 2021. 
 
You asked the Plan to pay for eyeglass lens enhancements. The Plan denied your request. The Plan says lens 
enhancements are excluded from coverage. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan covers single vision, lined bifocal, lined 
trifocal, and lenticular and frames. Therefore, we decided that the Plan does not have to pay for eyeglass lens 
enhancements provided on November 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021. 
 
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 the services were not billed correctly. 
 
 
 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 these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Volara high frequency chest wall oscillation device 
(E1399). 
 
You asked the Plan to pre-approve Volara high frequency chest wall oscillation device. You say that this 
should be considered as necessary for this enrollee's needs based on individual circumstances. The Plan denied 
your request. The Plan says this device is considered one of convenience based on its operating features. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same 
purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
We looked at the file and Medicare rules. The records show that the enrollee already has a chest wall 
oscillating device. Medicare guidelines state "Additional expenses for "deluxe" features, or items that are 
rented or purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. You can 
find this information in Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS), Section 90 - Payment for Additional Expenses for Deluxe 
Features. Based on this information, we decided that Medicare rules for coverage of Volara high frequency 
chest wall oscillation device have not been met. Therefore, we decided that the Plan does not have to pre-
approve Volara high frequency chest wall oscillation device (E1399).
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for the individual psychotherapy services (90832) provided October 27, 
2021. 
 
You asked the Plan to pay for the psychotherapy services. You say that please review the attached document 
and process the claim toward payment. The Plan denied your request. The Plan says that the listing of a 
referring provider on the claim does not satisfy the documentation criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. The only exception 
to the consultation requirement is in cases where the patient's primary care or attending physician refers the 
patient to the CP or LCSW. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have been met. Specifically, the record shows that the enrollee was 
referred to this provider by their attending/primary physician. Therefore, we decided that the Plan has to pay 
for the individual psychotherapy services (90832) provided October 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on November 9, 2021. 
 
You asked the Plan to pay for intraoral imaging. You say that you thought that these services were included. 
The Plan denied your request. The Plan says D0220 and D0230 are not covered dental services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
imaging (D0220 and D0230) provided by a participating provider on November 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH). 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (LTACH). 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where he/she is currently 
receiving care. 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 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 admission to a long-term acute care hospital (LTACH).