Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the magnetic resonance angiography 
(MRA) provided on October 21, 2021. 
 
You asked the Plan to waive the copayment for the magnetic resonance angiography (MRA). You say that you 
feel the services should be covered. 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 $195 
copayment for diagnostic radiology services, not including x-rays. 
 
You have been asked to pay a $195 copayment for the magnetic resonance angiography (MRA). This 
item/service falls within the diagnostic radiology services, not including x-rays 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 magnetic resonance angiography (MRA) provided on October 
21, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel labs provided on August 18, 2022. 
 
You asked the Plan to pay for general health panel labs. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for general health panel labs 
provided on August 18, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan must lower the coinsurance for a breast cancer screening. We decided that the Plan 
does not have to waive the coinsurance for a breast cancer screening. The Plan says that this cost sharing was 
charged correctly. 
 
You asked the Plan to lower the coinsurance for a breast cancer screening a breast cancer screening provided 
on April 20, 2022. You say that you disagree with the coinsurance. 
 
We decided that the Plan must lower the coinsurance for a breast cancer screening.  
The Plan follows Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all 
cost sharing information. Your contract with the Plan says that enrollees must pay a 40% coinsurance for a 
breast cancer screening. 
  
The Plan says you must pay $47.34 of the allowed amount of $117.63, or 41%, for a breast cancer screening. 
Based on the Plan contract, however, you cannot be asked to pay more than a 40% coinsurance for a breast 
cancer screening. The correct coinsurance for the allowed amount is $47.05($117.63 x 40% = $47.05). 
 
Therefore, we decided that the Plan must lower the coinsurance for a breast cancer screening.  
 
We also decided that the Plan does not have to waive the coinsurance for a breast cancer screening. 
 
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% 
coinsurance allowed amount for breast cancer screening. 
  
Therefore, we decided that the Plan does not have to waive the coinsurance for a breast cancer screening. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan 0.01% solution. 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Lumigan is a self-administered drug and does not fall under Part B 
coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan 0.01% solution.  
 Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on 
September 01, 2022. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that you thought any tests 
related to your physical would be covered. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies (laboratory tests). 
 
You have been asked to pay a $10 copayment for the laboratory services. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies (laboratory tests) 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 laboratory services provided on September 01, 2022.
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 was independent and active prior to 
hospitalization, this admission to acute rehabilitation facility is to maximize functional independence. The Plan 
denied your request. The Plan says the enrollee does not have complex medical and intensive rehabilitation 
needs requiring supervision by a rehabilitation physician and an intensive and coordinated interdisciplinary 
team in a resource intensive inpatient hospital environment. 
 
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 enrollee's mobility status is at a home care level of function and does not require 
intensive therapy or intensive rehabilitation services. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (85060) provided on August 21, 2022. 
 You asked the Plan to pay for the blood smear. You say that the service was billed for the date of interpretation 
and not for the date of collection and that service was rendered out of medical necessity. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the blood smear have not been met. Code 85060 have a PC/TC 
indicator of 8 and was billed with place of service 22 (Outpatient Hospital) which is not considered as an 
appropriate place of service per the Medicare guidelines. Therefore, we decided that the Plan does not have to 
pay for the blood smear (85060) provided on August 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat ganglion of impar with pulsed radiofrequency 
ablation (RFA) (64450). 
 
You asked the Plan to pre-approve RFA. You say that you are in extreme pain. You also say that you had this 
done 6 months ago with 50% pain relief. The Plan denied your request. The Plan says the requested service is 
medically necessary. 
 
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 pre-approve RFA. Our reviewer says that the 
requested RFA is not considered medically reasonable and necessary in this case. Our physician reviewer 
found a ganglion impar block and RFA are considered to be experimental and investigational because of 
insufficient evidence of the effectiveness for coccydynia, pelvic pain and other indication. Therefore, the 
reviewer found that the requested service is 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a repeat ganglion of impar with pulsed radiofrequency ablation (RFA) (64450).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded as 87481, 87491, 87496, 
87500, 87511, 87529, 87532, 87563, 87591, 87641, 87651, 87653, 87661 and 87798 provided June 28, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you do not personally see the patients and is 
dependent on receiving patient information from the ordering provider. The Plan denied your request. The Plan 
says the Plan does not have the information needed to consider this charge. 
 
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 laboratory services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that in a prior communication the Plan requested specific 
information in order for us to complete our review. The Plan needs all treatment records, which should include 
laboratory results, name of laboratory who performed the service, name and address of referring physician, 
copies of orders from referring physician and/or copy of letter of medical necessity or documentation that 
supports the necessity of the test performed, specimen body source. The review has determined that the 
items/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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services coded as 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87563, 87591, 87641, 87651, 87653, 87661 and 87798 provided June 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76700 billed for date of service September 1, 
2022. 
 
You asked the Plan to pay for procedure code 76700. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment for code 76700 is bundled into payment for code 93975. 
 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 76700 
is a column II code to column I code 93975. 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 76700 billed for date of service September 1, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx-SCC (0315U) provided on June 27, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the services were medically necessary and 
needed to be performed for the enrollee's condition. The Plan denied your request. The Plan says the service is 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory service have not been met. Per the MolDX program 
DEX Diagnostics Exchange, DecisionDx-SCC (0315U) is noncovered by Medicare. Therefore, we decided that 
the Plan does not have to pay for DecisionDx-SCC (0315U) provided on June 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 you do not qualify for SNF coverage. You do not have documented skilled nursing 
needs and you do not have documented skilled therapy needs. Daily skilled services are not shown to be 
required to establish a maintenance program or to prevent deterioration of your condition. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee used a noninvasive ventilation 
while he was in the hospital and was doing well with it. The enrollee was ordered to keep using a noninvasive 
ventilator when he was discharged from the hospital, but the ventilator was denied, and he was back in the 
hospital within 24 hours. The enrollee has rented a noninvasive ventilator and has not been readmitted to the 
hospital since he started using it. He desperately needs this device. The Plan denied your request. The Plan says 
the request is not medically necessary and does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found medical records document the 
diagnosis of chronic respiratory failure consequent to chronic obstructive pulmonary disease. Provided records 
also document that the home ventilator is being requested for use in intelligent volume assured pressure support 
(IVAPS) mode which could be provided by a BiPAP device with average volume assured pressure support and 
a back-up rate.  As stated in the Local Coverage Determination (L33800), claims for ventilators used to provide 
CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable 
and 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says admission to an LTACH is not medically 
necessary. 
 
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 that the enrollee appears to be improving with current treatment and should only 
require short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 
 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.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the paravertebral pulsed radiofrequency ablation (RFA) (64461, 64462) 
provided on July 15, 2022. 
 
You asked the Plan to pay for the RFA. You say that the services were medically necessary for the enrollee. 
The Plan denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the RFA. Our reviewer says that the 
requested RFA are considered medically reasonable and necessary in this case. Our physician reviewer found 
the provided documentation indicates that the enrollee has previously had successful RFAs. Therefore, the 
reviewer found that the requested services are medically reasonable and 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 RFA have been met. Therefore, we decided that the Plan has to pay for the 
paravertebral pulsed radiofrequency ablation (RFA) (64461, 64462) provided on July 15, 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: 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 an LTACH admission is medically 
necessary. The Plan denied your request. The Plan says you do not meet all the requirements for admission to 
an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the record indicates that you have ongoing acute medical issues and still require 
acute care services. You continue to receive acute care services, and these have not been denied. The medical 
record does not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH facility. The elements of the coverage rules are not satisfied.  
 
 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear (85060) provided on September 15, 2022. 
 You asked the Plan to pay for the blood smear. You say that the service was billed for the date of interpretation 
and not for the date of collection and that service was rendered out of medical necessity. The Plan denied your 
request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the blood smear have not been met. Code 85060 have a PC/TC 
indicator of 8 and was billed with place of service 22 (Outpatient Hospital) which is not considered as an 
appropriate place of service per the Medicare guidelines. Therefore, we decided that the Plan does not have to 
pay for the blood smear (85060) provided on September 15, 2022.