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

 
We decided that the Plan does not have to pay for Cystourethroscopy (separate procedure) (52000) provided on 
April 20, 2022. 
 
You asked the Plan to pay for Cystourethroscopy (separate procedure). You say that the out-of-network 
provider was the only available assistant at the time of the procedures and rendered services specifically 
requested by the in-network primary provider and in-network facility. The Plan denied your request. The Plan 
says this provider specialty for the rendering provider indicates "Specialist/Technologist, Other", which is not a 
covered provider. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for Cystourethroscopy (separate 
procedure) (52000) provided on April 20, 2022.
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 14, 2022 to March 15, 2022. 
 
You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says the enrollee was noted to to be a custodial resident during these dates. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee no longer qualified for SNF coverage after 2/13/2022. The enrollee 
did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy 
needs. The enrollee was ambulating more than 100 feet and tending to ADLs with minimal supervision. Daily 
skilled services were not required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. The enrollees care needs could, as a practical matter, be provided at a lower level of 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 SNF care 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 14, 2022 to March 15, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (0037U) provided on March 18, 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 say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. 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 laboratory 
services (0037U) provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on April 8, 2022. 
 
You asked the Plan to waive the copayment for an EKG. You say that in the past you have not been charged for 
this. 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 an EKG.  
 
 
 
 
 
 
 
 You have been asked to pay $20.68, which is less than the standard copayment for an EKG. This item/service 
falls within the non-radiological diagnostic 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 EKG provided on April 8, 2022.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the $5 copayment for a primary care office visit. We decided that the 
Plan does not have to waive the 20% ($1.18) coinsurance for a methylprednisolone injection.  
 
You asked the Plan to waive the copayment for a primary care office visit and a methylprednisolone injection 
provided on April 13, 2022.. You say that you saw your primary care provider and not a specialist, so you 
should not owe a $5 copayment. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for a primary care office visit.  
 
"The Plan follows Medicare rules. Medicare rules say that there is a $0 copayment for primary care visits.  
 
The file shows that you have a medical indication for which Medicare will cover this primary care visit. 
Therefore, we decided that the Plan has to waive the copayment for a primary care office visit.  
 
We also decided that the Plan does not have to waive the coinsurance for a methylprednisolone injection. 
 
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 a methylprednisolone injection. Therefore, we decided that the Plan does not have to waive the 
copayment for a methylprednisolone injection. The allowed amount of this item or service was $5.92, resulting 
in a coinsurance of $1.18 ($5.92 x 20% = $1.18). 
 
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 (81455) provide don May 22, 2022. 
 
You asked the Plan to pay for genetic testing. You say that the substantial clinical evidence provided above 
supports broad-panel NGS CGP testing for patients with recurrent, relapsed, refractory, metastatic, or advanced 
stages III or IV cancer that seek further treatment. The Plan denied your request. The Plan says the claim was 
billed with a date of service inconsistent with Medicare rules governing laboratory services. A specimen was 
collected on April 29, 2022, rather than the billed date of service May 22, 2022. There is no documentation to 
support genetic testing on the billed date of 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. 
 
We find that CPT code 81455 is not supported in the medical record. Specifically, there is no documentation to 
support genetic testing on the billed date of service. 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 (81455) provide don May 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for MRIs provided on May 13, 2022, and  
May 14, 2022. 
 
You asked the Plan to waive the copayment for the MRIs. You say that you were not told that you would be 
responsible to pay any dollar amount above your normal deductible. 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 $350 
copayment for an MRI.  
 
 
 
 
 You have been asked to pay $350 for the MRI provided on May 13, 2022. You have also been asked to pay 
$292.83 for the MRI provided on May 14, 2022, which is less than the standard $350 copayment. The total you 
owe is $642.83 ($350 + $292.83 = $642.83). These items/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 copayment for 
the MRIs provided on May 13, 2022, and May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 2, 2022, billed with 
codes 81455, 81479, 81301, 81479 and 81194. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like these codes reprocessed 
and approved for payment based on the supporting documentation presented. The Plan denied your request. 
The Plan says this claim has not been correctly 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 
May 2, 2022, billed with codes 81455, 81479, 81301, 81479 and 81194.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist. 
 
You asked the Plan to pre-approve these services. You say that your primary care physician referred you to this 
provider that specializes in Fragile X disorder. The Plan denied your request. The Plan says the services are 
available from network providers. 
 
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. The Plan confirmed that they have 
providers available who are qualified to treat your condition. 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 a 
referral to an out-of-network neurologist.
Appeal type: SNF
Decision: Partially Favorable

 
You asked the Plan to pay for skilled nursing facility (SNF) care provided from December 28, 2021, to 
February 1, 2022.. You say that you had to remain in the facility while waiting for medical equipment to be 
delivered to your home. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to pay for skilled nursing facility (SNF) care on date of service February 1, 
2022.  
 
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 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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide medical records pertinent to the skilled nursing facility 
(SNF) care you received on February 1, 2022. The Plan says that this SNF care was not medically necessary 
and is therefore not covered. Without medical records, we cannot determine whether the SNF care you received 
on February 1, 2022 was medically reasonable and necessary. Therefore, the Plan has not shown that its 
decision to deny payment for this date of service is medically correct or justified according to Medicare rules. 
Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care.  
 
We also decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) 
care provided from December 28, 2021, to January 31, 2022. 
 
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 $0 
copayment per day for days 1 to 20 and $150 copayment per day for days 21 to 100 for skilled nursing facility 
(SNF) care, up to a maximum out-of-pocket amount of $1,700 for 2022. At the time this claim was processed, 
$5 of the $1,700 maximum out-of-pocket amount had been met.  This SNF stay lasted 33 days, resulting in a copayment amount of $1,695 because this amount met the $1,700 
total maximum out-of-pocket amount for 2022. Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility (SNF) care. 
 
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: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on February 3, 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 that the services are not covered as billed. 
 
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 Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, we decided that the Plan has to pay for the laboratory services 
provided on February 3, 2022.  
 
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 pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care The Plan denied your request. The Plan says Medicare guidelines 
have not been met. Care can be provided in a different place such as in the home, outpatient, or long term 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is ambulating at a community level per functional independence measure 
standards. The enrollee is able to improve with repetitive exercise and support from non-skilled personnel. The 
enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found that the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that the device is medically necessary. The Plan 
denied your request. The Plan says you have asthma, restrictive lung disease, and obstructive sleep apnea. 
There is no documentation of bronchiectasis, no diagnosis of cystic fibrosis, and no diagnosis of neuromuscular 
disease. Criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
 
 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 HFCWOD. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation that you have 
cystic fibrosis, bronchiectasis or a neuromuscular disease. You do not have a qualifying condition for coverage 
of the requested chest wall oscillating device. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the FoundationOne Liquid CDx (F1LCDx) testing provided on April 
17, 2022. 
 
You asked the Plan to pay for the F1LCDx testing. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that the date of service for a clinical laboratory 
test or the technical component of physician pathology service must be the date the specimen was collected. 
 
The Plan must follow Medicare rules. The rules say that generally laboratory services should be billed with the 
date of specimen collection as the reported date of service; however, there are three exceptions to this rule. The 
rules also 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. Specifically, the Plan has not acknowledged nor addressed the possible 
exceptions to the rule applied in this case. The sample in this case was collected as part of a biopsy procedure 
performed in an outpatient hospital setting, so it is likely that an exception has been met in this case. Therefore, 
we decided that the Plan has to pay for the FoundationOne Liquid CDx (F1LCDx) testing provided on April 
17, 2022.  
 
  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 April 1, 2022, to April 27, 2022. 
 You asked the Plan to pay for SNF care. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee did not qualify for SNF coverage 4/1/2022- 4/27/2022. The enrollee 
did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy 
needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration 
of the enrollees condition. The enrollees care needs could, as a practical matter, be provided at a lower level 
of 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 SNF care 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 April 1, 2022, to April 27, 2022.