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

 
We decided that the Plan does not have to pre-approve elective surgery of the right wrist to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve elective surgery of the right wrist to be provided by an OON provider. You 
say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers 
that are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
elective surgery of the right wrist to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided 
from November 2, 2021, to November 30, 2021. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were not aware of any 
copayments after the first visit. The Plan denied your request. The Plan says you have been charged 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 $40 
copayment for each visit for rehabilitation services.  
 
The file shows you had a total of 9 physical therapy visits from November 2, 2021, to November 30, 2021. 
Therefore, you have been asked to pay a $40 copayment for each visit for the PT services. The total for all 
visits is $360 ($40 copayment x 9 visits = $360). The PT services fall within the Outpatient Rehabilitation 
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 copayments for physical therapy (PT) services 
provided from November 2, 2021, to November 30, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to pay for substance abuse treatment facility services provided January 11, 2022 
to February 7, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for substance abuse treatment facility services. You say that you spoke to your 
doctor that recommended that you got treatment immediately. The Plan denied your request. The Plan says that 
the services were provided out-of-network and were not approved in advance. 
 
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 has not included medical records, without medical records we cannot 
determine if the services provided were emergent or not. The Plan did not provide any other rationale or 
evidence to support a denial of payment for this service. Therefore, we decided that the Plan has to pay for 
substance abuse treatment facility services provided January 11, 2022 to February 7, 2022 by an out-of-
network (OON) provider.  
 
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 pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve an ILR. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 an ILR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic 
stroke or any other apparent indication for an ILR. In summary, there is insufficient documentation to support 
the medical necessity for insertion of an ILR in this enrollees clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an implantable loop recorder (ILR).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing services. 
 
You asked the Plan to pre-approve private duty nursing services. You say that this is medically necessary for 
your condition. The Plan denied your request. The Plan says private duty nurses are not covered under any 
condition. 
 The Plan must follow Medicare rules. The rules say that home health care services include skilled nursing care 
provided on an intermittent basis.  
 
We looked at the file and Medicare rules. In this case, the services of a private duty nurse do not meet the 
coverage criteria of skilled nursing care on an intermittent basis. Based on this information, we decided that 
Medicare rules for coverage of private duty nursing services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve private duty nursing services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tubal ligation. 
 
You asked the Plan to pre-approve tubal ligation. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that sterilization is covered when specific criteria are 
met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of tubal ligation have not been met. Therefore, we decided that the Plan does not have to pre-approve 
tubal ligation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DecisionDx Melanoma testing services (81529) provided to 
the enrollee on October 6, 2021. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the cancer was stage T1a with no mention of any difficulty with determining the stage 
(extent) of the melanoma. 
 
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 the enrollee has stage T1a melanoma, with a 0.6mm superficial spreading melanoma. There was been no 
sentinel biopsy done. As the enrollee is T1b, the criteria is not 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for DecisionDx Melanoma testing services (81529) 
provided to the enrollee on October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 2, 
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 laboratory report is not included, and the use of the XS modifier is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 not supported by the medical records. Our reviewer found the medical record must demonstrate 
the treating clinician who is responsible for the cardiovascular disease management is the ordering clinician. 
The medical record must clearly document the communication and discussion of pre-test and post-test 
counseling and the risk associated with genetic testing. The medical record must demonstrate disease 
appropriate phenotyping to establish clinical diagnosis or suspected diagnosis for which the test results would 
directly impact the management of the patients condition. The clinical actionability of the gene-disease 
relationship for the patient must be documented in the medical record. Tier 2 CPT codes 81401, 81402, 81403, 
81404, 81405 and 81406 are not appropriate to report for cardiovascular genetic testing. 
 
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 not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
August 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve targeted genomic sequence analysis. 
 
You asked the Plan to pre-approve targeted genomic sequence analysis. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that next-generation sequencing is covered when specific 
criteria 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 targeted genomic sequence analysis. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found per the NCCN 
Guidelines patients with stage T1cN0 non-small cancers do not requires additional treatment after resection or 
radiation. Next generation sequencing (NGS) is not recommended for these enrollees. The service is not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of targeted genomic sequence analysis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve targeted genomic sequence analysis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) rendered by the out-of-network (OON) provider on December 3, 
2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established 
patient (99335) rendered by the out-of-network (OON) provider on December 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 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 radiologic guidance codes include all imaging by the defined modality required to perform 
the procedure. 
 
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 the denied codes is: 
 
CPT 19081: 
 
Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and 
imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance 
 
CPT 77065: 
 
Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 
 
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 not supported by the medical records. A follow-up 
mammogram performed post tomosynthesis-guided breast biopsy will be considered part of the procedure and 
not separately payable, regardless of whether the patient is brought to a different room and/or unit for the 
mammography. Post- biopsy mammograms (77065 and/or 77067, with or without G0279) coded and billed for 
the same date of service, regardless of the timing, separation, number, and/or order of claims billed, will not be 
considered separately payable. Our reviewer found these codes do not meet the criteria for separate payment. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pay for imaging services provided to the enrollee on August 3, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Electrocardiogram (ECG) provided on December 23, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Electrocardiogram (ECG). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and it 
was determined these services were not urgent or emergent. 
 
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 Electrocardiogram 
(ECG) provided on December 23, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Veltassa. 
 
You asked the Plan to pre-approve Veltassa. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Veltassa.  
 
Benefits for Veltassa 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable pulse generator. 
 
You asked the Plan to pre-approve an implantable pulse generator. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
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 an implantable pulse generator. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record provided does not document that the requested service is as safe 
and efficacious for the enrollee's specific clinical condition as other standard therapies. The record provided 
does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 
service. The elements of the coverage criteria are not satisfied. The requested service is not 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 an implantable pulse generator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an implantable pulse generator.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee has not had the chance to complete a 
rehabilitation course. The Plan denied your request. The Plan says that the enrollee's needs can be safely 
managed in a less restrictive setting. 
 
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 continuation of services is medically reasonable and necessary. Our physician reviewer found as a 
practical matter, the enrollee requires continued daily skilled therapy and nursing services on an inpatient basis 
in the skilled nursing facility. The enrollee is documented as not yet being able to ambulate a safe household 
distance. The enrollee requires physical assistance with mobility and activities of daily living. The enrollee is 
benefiting from daily therapy, per the evaluating therapists. The enrollee requires daily skilled nursing for 
medical monitoring, per the medical notes. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an ultra-lightweight wheelchair. 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 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 ultra-lightweight wheelchair to be provided by an out-of-network (OON) provider.