Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 19 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that you are being discharged too soon and 
need additional PT. The Plan denied your request. The Plan says the additional visits are not medically 
reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
  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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for your condition. Our reviewer found that the records do not demonstrate that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, that the services can 
be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or 
under the supervision of a therapist. Our physician reviewer also found that the specialized skill, knowledge 
and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain 
your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 19 additional physical therapy (PT) visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim does not meet coding standards. 
 
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 
laboratory services provided to the enrollee on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 23, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
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 the 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 laboratory services provided to the enrollee on July 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 
15, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service December 15, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 18, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim does not meet coding standards. 
 
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 
laboratory services provided to the enrollee on October 18, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided by a 
network facility on November 11, 2021. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were not given any 
treatment during your emergency room visit. You say you should not be responsible for the copayment. The 
Plan denied your request. The Plan says you have been asked to pay 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 $90 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency care benefit category. The medical record shows services were rendered, including 
vitals and review of systems.  
 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 emergency room visit provided by a network facility on 
November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intravenous immune globulin (IVIG) therapy provided to the 
enrollee on October 18, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says there was no documented evidence of rapid progression of a covered disease or relapse. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found IVIG therapy will only be considered medically reasonable and necessary for neurological disorders 
when there is evidence of rapid progression of the disease or relapse or when other forms of treatment have 
failed or are contraindicated. The physician must document the rationale for the choice of therapy and consider 
disease activity, concurrent illness, venous access, side effects and drug availability in the decision of which 
therapy to prescribe and in what sequence. The review has determined that s the enrollee does not have a 
covered indication for this request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for intravenous immune globulin (IVIG) therapy provided to the enrollee on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the Part B drug, laboratory work, and the 
computed tomography (CT) scan provided by a network facility on October 5, 2021. 
 
 
 You asked the Plan to waive the cost sharing for the Part B drug, the laboratory work, and the CT scan. You 
say that the scan was not done at the hospital, and you say the cost of the drug is overpriced. You say you are 
being overcharged. The Plan denied your request. The Plan says you have been asked to pay 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 20% 
coinsurance for in-network Medicare Part B covered drugs, a $50 copayment laboratory services at an in-
network outpatient hospital, and a $150 copayment for advanced imaging services at an in-network outpatient 
hospital.  
 
You have been asked to pay $224 which is 20% of the allowed amount for the Part B drug. The allowed 
amount is $1,120. ($1,120 x 20% = $224). You have been asked to pay a $50 copayment for the laboratory 
work. You have been asked to pay a $100 copayment for the CT scan, which is less than the standard 
copayment amount. The Part B drug falls within the Medicare Part B prescription drugs benefit category. 
The laboratory work and the CT scan 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 cost sharing for the Part B drug, laboratory work, and the computed 
tomography (CT) scan provided by a network facility on October 5, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy visits provided on August 13, 2021, to 
August 27, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy visits. You say that the provider should have known they were 
out-of-network with Medicare before offering services. The Plan denied your request. The Plan says no prior 
authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy visits provided on August 13, 2021, to August 
27, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for azacitidine injections provided from May 
17, 2021, to October 8, 2021. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you feel the charged amounts are 
incorrect. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B chemotherapy drugs and administration. 
 
 
 
 Service/Drug Allowed Amount 20% Coinsurance 
Chemotherapy Administration $74.86 $14.97 
Azacitidine (May 17, 2021) $199.82 $39.96 
 $12.11 $2.42 
Azacitidine (May 18, 2021) $199.82 $39.96 
 $12.11 $2.42 
Azacitidine (May 19, 2021) $199.82 $39.96 
 $12.11 $2.42 
Azacitidine (May 20, 2021) $199.82 $39.96 
 $12.11 $2.42 
Azacitidine (May 21, 2021) $199.82 $39.96 
 $12.11 $2.42 
Total:  $226.87 
 
 
Service/Drug Allowed Amount 20% Coinsurance 
Chemotherapy Administration $74.86 $14.97 
Azacitidine (October 4, 2021) $148.64 $29.73 
 $13.94 $2.79 
Azacitidine (October 5, 2021) $148.64 $29.73 
 $13.94 $2.79 
Azacitidine (October 6, 2021) $148.64 $29.73 
 $13.94 $2.79 
Azacitidine (October 7, 2021) $148.64 $29.73 
 $13.94 $2.79 
Azacitidine (October 8, 2021) $148.64 $29.73 
 $13.94 $2.79 
Total:  $177.57 
 
You have been asked to pay a total of $404.44, which is 20% of the allowed amount for the injections. The 
injections fall within the Medicare Part B Prescription Drugs 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 azacitidine injections provided from May 17, 2021, to October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment 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 to be rendered by the out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical services provided to the enrollee on June 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied code is not supported in the medical records submitted. 
 
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 23420 is "Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the procedure report noted an arthroscopic 
subacromial decompression was performed. Type 2 acromion was converted to a type 1 acromion. The bursal 
side of the cuff again showed the previously described full-thickness tear. "A moderately-retracted full 
thickness tear was identified...Conversion of the procedure was then to an open rotator cuff reconstruction. 
Deltoid splitting approach was performed. The cuff tissue was mobilized. Stay sutures were placed." The 
surgical procedure report from 5/721 does support that CPT 23420- reconstruction of complete shoulder 
(rotator) cuff avulsion, chronic (includes acromioplasty)- was rendered in this case. 
 
We looked at this coder'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 pay for 
surgical services provided to the enrollee on June 22, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitation provided 
in an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee can safely receive the services they need in an alternate setting. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Liquid CDx test provided to the enrollee 
on September 7, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the request does not meet Medicare rules as the same cancer genetic content was previously 
assessed without progression of disease between tests. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the FoundationOne Liquid CDx test provided to the enrollee 
on September 7, 2021. The review has determined that the services at issue in this case were not medically reasonable or 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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOne Liquid CDx test provided to the enrollee on September 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vacuum erection device (code L7900) 
 
You asked the Plan to pre-approve a vacuum erection device. You say that you need this device for vascular 
therapy for erectile dysfunction. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices are statutorily non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a vacuum erection device have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a vacuum erection device (code L7900)
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by a 
network facility from November 26, 2021, to December 8, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel both hospital 
claims should be treated as the same stay and covered with one copayment due to being transferred from one 
hospital to another hospital during your visit. The Plan denied your request. The Plan says you have been asked 
to pay 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 $360 
copayment per day for days 1 to 5 for covered hospital care and a $0 copayment for additional Medicare-
covered days during your hospital admission.  
 
You have been asked to pay a $360 copayment for each day, days 1 to 5 of the inpatient hospital stay. ($360 x 
5 = $1,800). The inpatient hospital stay falls within the Inpatient hospital care benefit category. The record 
shows there were two separate hospital admissions. 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 inpatient hospital stay provided by a network facility from November 26, 2021, to December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on May 27, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the facility claim was billed as outpatient. This claim was billed as inpatient which is not 
correct. This claim must be rebilled as outpatient to match the facility submission.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due 
to an issue with the place of service code. Therefore, we decided that the Plan does not have to pay for medical 
services provided to the enrollee on May 27, 2021.