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

 
We decided that the Plan does not have to pre-approve Xtandi. 
 
You asked the Plan to pre-approve Xtandi. You say that you would like Xtandi to be approved for the enrollee. 
The Plan denied your request. The Plan says Xtandi is not covered under the enrollee's contract under any 
normal circumstances. 
 
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 Xtandi.  
 
Benefits for Xtandi 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wrist brace provided on March 26, 2022. 
 
You asked the Plan to pay for the wrist brace. You did not provide a specific argument for coverage. The Plan 
denied your request. The Plan says there is insufficient documentation to pay this claim. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. The record does not contain a valid proof of delivery or relevant medical 
records which support medical necessity for the supplies provided in this case. Therefore, we decided that the 
Plan does not have to pay for the wrist brace provided on March 26, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specimen validity testing (83789) provided on February 
15, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing shall not separately bill the validity testing.  
 
We looked at the file and Medicare rules. The requested specimen validity testing is not separately payable 
from the drug testing. 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 specimen validity testing 
(83789) provided on February 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continued acute inpatient psychiatric level of care. 
 
You asked the Plan to pre-approve a continued acute inpatient psychiatric level of care. You say that the 
enrollee requires additional treatment. The Plan denied your request. The Plan says a continued acute inpatient 
psychiatric level of care is not medically necessary. 
 
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 a continued acute inpatient psychiatric 
level of care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient 
psychiatric care. Our physician reviewer found it is not expected this enrollee would improve in a reasonable 
period of time beyond the dates in question as they were not showing any dangerousness to self or others, 
auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of 
safety. Our reviewer also found that it does 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. 
 
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 continued acute inpatient psychiatric level of care have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continued acute inpatient psychiatric level 
of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on February 28, 2022. 
 
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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that, for Medicare purposes, a chiropractor must place an 
AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. 
 
We looked at the file and Medicare rules. The file shows that the services were not billed with the required AT 
modifier. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on 
February 28, 2022.  
 
Please note that the Plan confirmed you owe $0 for these services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out-of-network (OON) physical therapy 
(PT) services provided on January 21, 2022. 
 
You asked the Plan to waive the copayment for the OON PT services. You say that you cannot afford the 
copayment. 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 out-of-network therapy visit.  
 The file shows that the Plan verified the provider is not a network provider. Therefore, you have been asked to 
pay a $40 copayment for the OON PT services. The OON 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 copayment for out-of-network (OON) 
physical therapy (PT) services provided on January 21, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on April 4, 2022. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the testing is not 
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 pay for the drug testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the medical records indicate the enrollee's pain is well controlled with the current pain management 
plan. The records also state the enrollee has been taking medicines as directed and there are no concerns. The 
records do not indicate accurate measurement of 22+ drugs is necessary to make clinical decisions, based on 
the specific medical assessment by the provider.  
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 drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for the definitive drug testing provided on April 4, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on November 2, 2021, to November 29, 2021. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services were necessary 
and were billed appropriately. The Plan denied your request. The Plan says Medicare does not separately pay 
for ESRD-related laboratory testing. The Plan also says these services were not billed with a modifier to 
indicate that they are not ESRD-related services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory 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 the laboratory services related to end-stage renal disease (ESRD) provided on 
November 2, 2021, to November 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on February 24, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed 
based on the medical necessity. The Plan denied your request. The Plan says the criteria for coverage have not 
been met as there was no documented contact with the attending/primary care physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the psychotherapy services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for the psychotherapy services 
provided on February 24, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can get the care you need at a lower level such as a skilled nursing 
facility. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for kyphoplasty. The 
enrollees medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 19, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service 
April 19, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on March 16, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this service should be covered. The Plan 
denied your request. The Plan says the copayment applied 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 $100 
copayment for each emergency room visit.  
 
You have been asked to pay $100 copayment for ER visit. ER visits fall within the Emergency Care 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 ER visit provided on March 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided on November 10, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were provided at the request of a 
physician and were medically necessary. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
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 lab 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 lab services (G0483) provided on November 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and wound debridement 
provided on January 28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care and wound debridement. You say that due to the 
place of service settings, it is not always possible to obtain an authorization for every visit prior  to the provider 
rendering the services. The Plan denied your request. The Plan says a review confirmed that there was no prior 
authorization submitted to the Plan to request coverage for out-of-network care with skilled nursing facility 
wound care service. The Plan also says that the member was in a skilled nursing facility stay that was not 
covered by them. 
 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 subsequent nursing facility care, and wound 
debridement provided on January 28, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplicate radiology service provided to the enrollee on 
February 28, 2022. 
 
You asked the Plan to pay for the services. You say that the denied charge should be reconsidered. The Plan 
denied your request. The Plan says this is a duplicate claim. 
 
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 70450 is not supported in the medical record. Specifically, there is no evidence that two 
separate services were performed in this case. 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 a 
duplicate radiology service provided to the enrollee on February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel, solid organ or 
hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (81455) 
provided October 15, 2021. 
 
You asked the Plan to pay for the genetic biomarker testing. You say that this targeted genomic sequence panel 
of 51 or greater genes was medically necessary based on past medical history. The Plan denied your request. 
The Plan says this service is not reasonable or medically necessary.  
The Plan must follow Medicare rules. Medicare rules say that biomarker testing is covered for the indications 
established in the applicable LCD. 
 
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 targeted genomic sequence analysis 
panel, 51 or greater genes. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found that the request for a panel of 51 or greater 
genes is not reasonable or medically necessary according to the coverage criteria established in the LCD. 
 
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 targeted genomic sequence analysis panel, 51 or greater genes have not been 
met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis 
panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or 
greater genes (81455) provided October 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a chiropractic visit with an out-of-network 
provider on January 10, 2022. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that after a ten-hour drive, you 
experienced sharp pains in your lower back that made it difficult to walk and perform activities of daily living. 
You say the chiropractic care significantly helped you and do not think you should owe anything. The Plan 
denied your request. The Plan says the cost-share 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 50% 
coinsurance of the Medicare-allowed amount for each Medicare-covered chiropractic visit. 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 a chiropractic visit with an out-of-network 
provider, on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code Q4169 billed for date of service March 4, 
2022, to April 1, 2022. 
 
You asked the Plan to pay for procedure code Q4169. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says procedure code Q4169 is not payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code Q4169 has a status indicator of E on the Physician Fee Schedule. This means that 
procedure code Q4169 is not payable. Based on this information, we decided that Medicare rules for coverage 
of procedure code Q4169 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code Q4169 billed for date of service March 4, 2022, to April 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure codes 0356T, 66984) provided 
to the enrollee on November 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 denied codes remain 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. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 0356T: 
 
Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into 
lacrimal canaliculus, each 
 
 
 CPT 66984: 
 
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or 
mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic 
cyclophotocoagulation 
 
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 that the medical record contains two 
procedure reports, dated November 3, 2021 and October 25, 2021. The date of service that was billed was 
November 2, 2021. Neither code was documented in the medical record for the correct date of service. 
 
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 surgical services (procedure codes 0356T, 66984) provided to the enrollee on November 2, 
2021.