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

 
We decided that the Plan does not have to pay for physician's services provided on May 9, 2022. 
 
You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on May 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are appealing this cost-
sharing. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for specialist visit.  
 
 
 
 
 You have been asked to pay $25 for a specialist visit. This item/service falls within the specialist visit 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 specialist visit provided on June 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from July 17, 2021, to 
July 24, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this was 
billed correctly. The Plan denied your request. The Plan says the records do not support the acute pancreatitis 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 246, percutaneous cardiovascular procedures 
with drug-eluting stent with major complications or comorbidities, or 4+ arteries or stents, and diagnosis 
K85.90, acute pancreatitis without necrosis or infection, unspecified. 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 services at the DRG originally billed. Our reviewer says 
that the billed DRG is not supported. Our physician reviewer found there was no imaging to evaluate the 
pancreas and no follow-up lipase level to support the acute pancreatitis diagnosis.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from July 17, 2021, to July 24, 2021, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crutch substitute knee scooter (E0118). 
 
You asked the Plan to pre-approve the crutch substitute knee scooter. You say that this is necessary based on 
your medical condition. The Plan denied your request. The Plan says this item is not considered medical in 
nature and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient published clinical literature 
demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for the 
crutch substitute knee scooter. Based on this information, we decided that Medicare rules for coverage of the 
crutch substitute knee scooter have not been met. Therefore, we decided that the Plan does not have to pre-
approve the crutch substitute knee scooter (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) and nutritional counseling 
(D1310) provided on August 8, 2022. 
 
You asked the Plan to pay for hygiene instructions and counseling. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says oral hygiene instructions (D1330) and nutritional 
counseling (D1310) are not covered by your dental benefits. 
 
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 oral 
hygiene instructions (D1330) and nutritional counseling (D1310) provided on August 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code T1001 billed for date of service March 13, 
2022. 
 
You asked the Plan to pay for procedure code T1001. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the billed code is invalid 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 procedure code. 
 
We find that procedure code T1001 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code T1001 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code T1001 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code T1001 billed for date of service March 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to the IRF 
was denied as not meeting criteria, is not medically necessary, and a lower level of care might be appropriate 
such as a skilled nursing facility or home health care, for further skilled therapy needs. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for non-displaced sternal fracture after a motor vehicle collision. Medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical 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 the 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for levocarnitine injections and physical 
therapy provided on August 9, 2022, and August 11, 2022.  
 
 
 You asked the Plan to waive the cost sharing for levocarnitine injections and physical therapy provided  
August 9, 2022, and August 11, 2022. You say that you are appealing this cost-sharing. The Plan denied your 
request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered chemotherapy drugs and 20% coinsurance for other Medicare Part B 
covered drugs. Your contract with the Plan also clearly says that you must pay a $30 copayment for each 
physical therapy and/or speech and language pathology visit.  
 
You have been asked to pay $40.60 for a levocarnitine injection provided on August 9, 2022 ($203 x 20% 
coinsurance = $40.60). You have been asked to pay $30 for physical therapy provided on August 9, 2022. You 
have been asked to pay $40.60 for the levocarnitine injection provided on August 11, 2022 ($203 x 20% 
=$40.60). You have been asked to pay $30 for physical therapy provided on August 11, 2022. The total you 
owe is $141.20 ($40.60 + $30 + $40.60 + $30 = $141.20). The levocarnitine injections fall within the Medicare 
Part B drugs benefit category. The physical therapy falls within the physical 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 cost sharing for levocarnitine injections and physical therapy provided on 
August 9, 2022, and August 11, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiovascular panel (81410, 81411, 
81414 and 81413) provided on November 16, 2021. 
 
You asked the Plan to pay for the cardiovascular panel. You say that these services were medically necessary 
and should be paid. The Plan denied your request. The Plan says this test does not meet the criteria for medical 
necessity. 
 
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 cardiovascular panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the provided test is described as a genetic-based cardiovascular risk factor 
screening test in which multiple genes are assessed using genomic DNA extracted from patient sampling. It 
assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with 
increased cardiac risk. It is not a diagnostic test. There is no evidence to support the role of this test in this 
patients clinical management. In summary, the requested testing is not considered reasonable or 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 cardiovascular panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the comprehensive cardiovascular panel (81410, 81411, 81414 and 81413) provided 
on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (POV) 
(K0800). 
 
You asked the Plan to pre-approve a Group 1 standard POV. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 Group 1 standard POV. Our reviewer 
says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee's functional status is not addressed. The record does not provide evidence the enrollee 
requires a power operated device to manage MRADLs in the home. 
 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 Group 1 standard POV have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Group 1 standard power operated vehicle (POV) (K0800).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on May 10, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G0483 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 
15-21 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 31, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you have included a letter that 
shows approval of all services for your CT, including the visit. The Plan denied your request. The Plan says 
this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for an in-network specialist visit.  
 
 
 
 
 
 
 
 You have been asked to pay a $35 copayment for a specialist visit. This item/service falls within the specialist 
visit 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 specialist visit provided on 
May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care, a laminectomy (63047), a 
posterior segmental instrumentation (22842), an arthrodesis for the lumbar (22633) and an arthrodesis for 
single interspace. 
 
  You asked the Plan to pre-approve acute inpatient hospital care, a laminectomy (63047), a posterior segmental 
instrumentation (22842), an arthrodesis for the lumbar (22633) and an arthrodesis for single interspace. You 
say that you are on disability for lower back, you have spinal stenosis, and are in immense pain. You also say 
that your blood pressure has elevated, and you are not in good health. The Plan denied your request. The Plan 
says based on the clinical information they received; this request is not medically necessary. 
 
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.  The rules also say that medically necessary services are those that are reasonable and necessary for the 
diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the 
functioning of a malformed body member. 
 
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 acute inpatient hospital care. 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 medical records show that the patient has 2 level degenerative discs 
without instability, fracture, or lesion. Our physician reviewer also found that the criteria for 2 level fusion 
surgery are not met. Our physician reviewer also says that there is no indication for this surgery and the surgery 
is not needed. Our physician reviewer also says that since the surgery is not needed, the inpatient admission is 
not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care and the surgical services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care, a laminectomy 
(63047), a posterior segmental instrumentation (22842), an arthrodesis for the lumbar (22633) and an 
arthrodesis for single interspace.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0037U) billed for date of service June 21, 
2022. 
 
You asked the Plan to pay for genetic testing. You say that the services at issue were billed correctly. The Plan 
denied your request. The Plan says the claim for this molecular pathology testing did not include the required 
unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of genetic testing have 
not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) billed for 
date of service June 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
04/02/2022, to 04/08/2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that that member has a 
hardship paying the copayment. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment per day for days 1-5 and $0 after day 5 for inpatient hospital care.  
 
 
 
 
 
 
 The enrollee has been asked to pay a $350 copayment per day for days 1-5 and $0 after day 5 for inpatient 
hospital care. The total amount you are being asked to pay is $1,750 ($350 x 5days = $1,750). This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for inpatient hospital care provided from 04/02/2022, to 04/08/2022.
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. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the current 
acute care setting.  
 
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.