Persius/hicric huggingface dataset:
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 records provided support the need for care in an 
IRF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the enrollee's condition is not at a level of complexity that requires an intensive and coordinated 
interdisciplinary approach including physician visits at least three times a week. 
 
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 
was admitted for chest pain and congestive heart failure after recent surgical repair of a hip fracture. The 
enrollee's 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for targeted genomic sequence analysis (81455) provided 
November 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the F1Heme test is a proven medically 
necessary covered benefit for comprehensive genomic testing for cancer. The Plan denied your request. The 
Plan says does not meet Medicare NCD/LCD criteria. 
 
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 find that CPT code 81455 is not supported in the medical record. Specifically, the next 
generation sequence testing (NGS) testing panel performed included testing for the FANCC gene. Testing for 
this gene is not a Medicare benefit and is statutorily excluded service. In addition to single gene testing, panels that include the FANCC gene are statutorily excluded service.  Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for targeted genomic sequence analysis (81455) provided November 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc syringe (J7329). 
 
You asked the Plan to pre-approve Trivisc. You say that you have had cortisone shots in the past in other places 
other than your knee. You say that they did not work. You also say that you would like to not have cortisone 
and just go with the next step. The Plan denied your request. The Plan says all of the criteria have not been met.  
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all 
of the conditions are met. 
 
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 Trivisc. Our reviewer says that the 
Trivisc injection does not meet the criteria for coverage. Our physician reviewer found the provided 
documentation indicates that the enrollee has failed conservative treatment and non-steroidal anti-
inflammatories. The reviewer did not find that the enrollee has tried and failed an intra-articular corticosteroid 
injection. Therefore, the reviewer found that the criteria for coverage have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc syringe (J7329).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray on August 20, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you were unaware there was a separate 
copayment for an x-ray. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 copayment for Medicare-covered x-rays. The charged amount was $33.24. 
 
You have been asked to pay $33.24 for an x-ray. An x-ray falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an x-ray on August 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (87150, 87641) provided on August 31, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are 
bundled. 
 
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 87641 is a column II code to column I code 87150. We have also confirmed that code 87150 is a column II code to 
column I code 87500. 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 the services (87150, 87641) provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit on March 14, 2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you shouldnt have a copayment 
for telehealth visits. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. 
 
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 Telehealth Services for Specialist Virtual. Covered services include: Certain telehealth services, 
including services by primary care providers (PCPs) and specialists.  
 
You have been asked to pay a $25 copayment for telehealth visit. Telehealth visits fall within the 
Physician/Practitioner services, including doctor's office visits 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 telehealth visit on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) surgical oncologist. 
 
You asked the Plan to pre-approve an office visit. You say that you have been going to this facility since 2008, 
and the physician you were seeing just retired. The Plan denied your request. The Plan says the services have 
been requested out-of-network and there are in-network providers available. 
 
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 
an office visit to be provided by an out-of-network (OON) surgical oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Octreotide injection. 
 
You asked the Plan to pay for Octreotide injection. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for Octreotide injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of a modality to 1 or more areas; electrical 
stimulation (unattended) (97014) provided February 2, 2022, February 16, 2022. 
 
You asked the Plan to pay for electrical stimulation (97014). You say that services should be covered. The Plan 
denied your request. The Plan says this code is not covered by Medicare. 
 
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 97014 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code 97014 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of electrical stimulation (97014) have not been met. Therefore, we decided that the Plan does not have to pay for the application of a modality to 1 or more areas; electrical stimulation (unattended) (97014) 
provided February 2, 2022, February 16, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on September 15, 2021. 
 
You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says a LMFT is not 
eligible to enroll in Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist.  
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 13, 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 are not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening 
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care. 
 
You asked the Plan to pre-approve inpatient psychiatric care. You say that the records provided support the 
need for continued inpatient psychiatric care. The Plan denied your request. The Plan says the requested care is 
not medically necessary because the records show that the enrollee's condition has improved and she is no 
longer a threat to herself. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
involuntarily admitted to the acute inpatient psychiatric hospitalization on June 30, 2022, with Generalized 
Anxiety Disorder. Based upon review the records provided it was not expected this enrollee would improve in 
a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation, auditory 
or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to 
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute 
inpatient level of care rather than a lower level of care beyond the dates in question as she did not have 
dangerousness to self or others and was compliant with her treatment. The health plans denial of continued 
inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health 
treatment beyond the date in question as she was not a danger to herself or others and does not have auditory or 
visual hallucinations. It did not appear that the services were reasonably expected to improve the enrollees 
condition or for the purpose of diagnosis beyond the date in question. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient psychiatric care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physician services rendered on January 
19, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that you have a $0 cost share for 
laboratory services. The Plan denied your request. The Plan says the copayment was applied 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 $10 
copayment for services obtained from a primary care provider.  
 
Review of the file shows that you received anticoagulation services from your primary care provider on 
January 19, 2022. You have been asked to pay a $10 copayment for these services. These services fall within 
the services obtained from a primary care provider 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 physician services rendered on January 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visits provided on October 28, 2021 
and December 22, 2021. 
 
You asked the Plan to waive the copayment for office visits. You say that you did not see the doctor on these 
dates.  The Plan denied your request. The Plan says you have been charged the correct copayment 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 $15 
copayment for each Medicare-covered primary care doctor visit (including telehealth services, nationally 
contracted walk-in clinic services, and urgently needed services). 
 
You have been asked to pay a total of $30 ($15 x 2 visits = $30). The office visits fall within the 
Physician/Practitioner services, including doctors office visits 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 office visits provided on October 28, 2021 and December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care discharge management (99217) provided on 
January 14, 2022. 
 
You asked the Plan to pay for observation care discharge management. You say that the services at issue were 
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
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 99217 is "Observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
'observation status' if the discharge is on other than the initial date of 'observation status.' To report services to a 
patient designated as 'observation status' or 'inpatient status' and discharged on the same date, use the codes for 
Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as 
appropriate.])" 
 
We find that CPT code 99217 is not supported in the medical record. Specifically, the available records indicate that the enrollee received discharge management services on the same day that the enrollee was 
classified as receiving observation care. The CPT code at issue should not be used in this scenario. Based on 
this information, we decided that Medicare rules for coverage of observation care discharge management have 
not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge 
management (99217) provided on January 14, 2022.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for home health services provided on February 7 to March 8, 2022. 
 
You asked the Plan to pay for home health services. You say that you have provided documentation to support 
the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met 
because a Notice of Admission was not provided. 
 
The Plan must follow Medicare rules. Medicare rules say that HHAs submit an NOA at the beginning of an 
admission and then submit one claim for each 30-day period of care. 
 
We looked at the file and Medicare rules. In this case, the case record strongly suggests that an NOA was 
submitted at the time of the first episode of care. A second NOA is not necessary. The Plan has not specifically 
addressed whether an NOA was submitted at the time of the first episode of care. It is the Plan's responsibility 
to substantiate its denial. In this case, the denial has not been substantiated so we must find in your favor. 
Therefore, we decided that the Plan has to pay for home health services provided on February 7 to March 8, 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 29, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to appeal the denial of the claim. The 
Plan denied your request. The Plan says the provider is out-of-network, and it was determined these services 
can be received in-network. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. 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. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on September 29, 2021 by 
an out-of-network (OON) provider.