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

 
We decided that the Plan does not have to pre-approve the Ambry CancerNext Hereditary Cancer test. 
 You asked the Plan to pre-approve the Ambry CancerNext Hereditary Cancer test. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says criteria for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS testing is covered when the enrollee has 
either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
We looked at the file and Medicare rules. The enrollee's records do not show that the enrollee has advanced, 
metastatic, recurrent, and refractory cancer. Based on this information, we decided that Medicare rules for 
coverage of the Ambry CancerNext Hereditary Cancer test have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Ambry CancerNext Hereditary Cancer test.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the immunizations and an office visit on 
September 5, 2023, to September 6, 2023. 
 
You asked the Plan to waive the coinsurance for the immunizations and an office visit. You say that you never 
had to pay coinsurance before. 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 47% 
coinsurance of the Medicare-allowed amount for out-of-network immunizations. You must pay a 47% 
coinsurance of the Medicare-allowed amount for out-of-network office visits.  
 
You have been asked to pay a 47% coinsurance for the immunizations and an office visit. This item/service 
falls within the immunizations and 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. The total amount 
you owe is $96.16, which is 47% coinsurance of the allowed amount for each item. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the immunizations and an office visit on September 5, 
2023, to September 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight psychotropic assay test (03454U) provided 
August 20, 2023. 
 You asked the Plan to pay for the genetic testing. You say that you request reconsideration of the denial that 
GeneSight Psychotropic is not medically necessary. The Plan denied your request. The Plan says the requested 
GeneSight testing does not meet Medicare criteria and is not medically reasonable and 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 genetic testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on review the records provided the medication has not been found to be useful in 
assistance with the enrollees condition as his notes state that depression remains in remission and attention 
deficit hyperactivity disorder (ADHD) symptoms were well-managed. The Medicare LCD L38394 requires the 
patient to be tried on at least one medication. The ordering psychiatrist must be board certified in psychiatry or 
neuropsychiatry. The ordering physician for this test is not a psychiatrist and is not boarded in psychiatry or 
neuropsychiatry. Documentation does not show the need for medication change or adjustment. Utilizing the 
information from provided and from Medicare LCD L38394, this enrollee does not meet the criteria for 
GeneSight Psychotropic Assay and is not considered medically necessary and reasonable in the treatment of 
this individual. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the GeneSight psychotropic assay test (03454U) provided August 20, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy visits (97110, 97116) 
provided on August 01, 2023, to August 16, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visits (97110, 97116). You say that they 
only put an ice pack on me and sent me home. I feel I should not have to pay for the services. 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 $40 
copayment for outpatient rehabilitation services. 
 
You have been asked to pay a $40 copayment for the physical therapy visits (97110, 97116). This item/service 
falls 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. The total you owe is $200 ($40 COST SHARE x 5 visits = $200). 
Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy visits 
(97110, 97116) provided on August 01, 2023, to August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on May 16, 2023, billed with 
procedure code 01922-QZ-P4-QS. 
 
You asked the Plan to pay for the practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the service exceeds the frequency allowed within 
time period.  
The Plan must follow Medicare rules. Medicare rules say that anesthesia codes describe a general anatomic 
area or service which usually relates to a number of surgical procedures, often from multiple sections of the 
CPT Professional. For Medicare purposes, only one anesthesia code is reported unless the anesthesia code is an 
Add-on Code (AOC). 
 
We looked at the file and Medicare rules. The documentation provided confirms that another anesthesia code 
(00630-QZ-P2) was reported by the same provider group on the same date of service and paid on June 4, 2023. 
Based on this information, we decided that Medicare rules for coverage of the practitioner services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for practitioner services provided 
on May 16, 2023, billed with procedure code 01922-QZ-P4-QS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis (L0650). 
 
You asked the Plan to pre-approve the orthosis. You say that you are appealing the denial because you need 
this back brace. The Plan denied your request. The Plan says under Medicare rules, the requested back brace 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 pre-approve the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of osteoarthritis of the right knee, hip, and intervertebral disc 
degeneration of the lumbar spine. A request for a lumbar brace was made. However, the provided 
documentation does not support that the enrollee had a recent injury or surgery, has a deformed spine, or have 
objectively weak muscles of the back to support this request for a back brace. Therefore, the LCD 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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar-sacral orthosis (L0650).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the myocardial perfusion imaging, cardiovascular stress test, 
technetium tc-99m tetrofosmin, and regadenoson injection billed with codes 78452, 93015, A9502 and J2785 
provided on February 17, 2023. 
 You asked the Plan to pay for the testing and injection. You say that the services were billed correctly and 
should be paid. The Plan denied your request. The Plan says the diagnosis code at issue is not appropriate as a 
primary diagnosis. 
 
The Plan must follow Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. These guidelines state that certain codes are manifestation codes, denoted with a code first note, or 
in diseases classified elsewhere in the code definition. Another diagnosis code should be sequenced before a 
manifestation code if applicable.  
 
We looked at the file and Medicare rules. This claim was billed with a code beginning in Z01 as a secondary 
diagnosis. This is among the codes listed as being principal diagnosis only, except when there are multiple 
encounters on the same day. This claim is not for multiple encounters. Based on this information, we decided 
that Medicare rules for payment of this claim have not been met. Therefore, we decided that the Plan does not 
have to pay for the myocardial perfusion imaging, cardiovascular stress test, technetium tc-99m tetrofosmin, 
and regadenoson injection billed with codes 78452, 93015, A9502 and J2785 provided on February 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (87798, 87481) provided on June 29, 
2023. 
 
You asked the Plan to pay for laboratory services. You say that these services were necessary and were 
reported appropriately. The Plan denied your request. The Plan says there is insufficient documentation to 
support the services reported on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of laboratory services have been met. 
Specifically, the limited records provided indicate that a single panel was requested for testing, and there are no 
test results included in these records. Without results, we cannot verify the services were provided as billed. 
Therefore, we decided that the Plan does not have to pay for laboratory services (87798, 87481) provided on 
June 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for out-of-network office visits provided on 
August 29, 2023. 
 
You asked the Plan to waive the coinsurance for out-of-network office visits. You say that you should not be 
responsible for these copayments. 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 47% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 47% coinsurance for out-of-network office visits. This item/service falls 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. The total you owe is $109.12 ($58.76 + $50.36 = 
$109.12). Therefore, we decided that the Plan does not have to waive the coinsurance for out-of-network office 
visits provided on August 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infusion supplies provided from July 
9, 2022, to July 13, 2022. 
 
You asked the Plan to waive the coinsurance for the infusion supplies. You say that you should not be 
responsible for items you did not order. 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 20% 
coinsurance for in-network home infusion therapy, including supplies.  
 
You have been asked to pay 20% coinsurance of the allowed amount for the infusion supplies. These items 
falls within the home infusion therapy benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the infusion supplies provided from July 9, 2022, to July 13, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service July 19, 
2023.  
 
You asked the Plan to pay for procedure code 76641. You say that the service was billed correctly and should 
be paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.   
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliances (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that you are 
requesting an appeal regarding the denial for the Flexitouch pneumatic compression device and garments. The 
Plan denied your request. The Plan says the records do not show that the enrollee has met the guidelines 
requirements. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
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 pneumatic compression device and 
appliances. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee is diagnosed with venous insufficiency and 
related lymphedema. A request for Flexitouch pneumatic compression device and garments was made. The 
notes describe the enrollee as with no open sores, no active ulcers, and not compliant or not using compression 
which are required to meet criteria for this device. Therefore, Medicare coverage criteria are not met based on 
the provided documentation.  
 
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 pneumatic compression device and appliances have not been met.  Therefore, 
we decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliances (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radiofrequency ablation. 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you are in a lot of pain and the pill 
are not enough for your joint pain. You say that you need this injection. The Plan denied your request. The Plan 
says the radiofrequency ablation 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 pre-approve the radiofrequency ablation. Our 
reviewer says that the radiofrequency ablation is not medically necessary. Our physician reviewer found that 
there is a lack of recent progress notes and imaging addressing the return of the enrollee's back pain. Therefore, 
the LCD coverage criteria has not been met, and the request is not 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 radiofrequency ablation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radiofrequency ablation.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says the requirements for IRF services are not medically necessary.  
 
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 medical problems are stable and there are no complex nursing or 
rehabilitation needs. The enrollee does not require treatment by multiple therapies and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical or occupational therapy, 
there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different 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 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
31, 2023. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you dont feel a 
copayment should be charged due to the arranged ambulance transport arriving 2 hours late for the pickup. 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 $200 
copayment for ambulance services. 
 
You have been asked to pay a $200 copayment for the ambulance services. This item/service falls within the 
ambulance 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 the ambulance 
services provided on May 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab panel provided on September 14, 2022. 
 
You asked the Plan to pay for the panel. The Plan denied your request. The Plan says the panel should be billed 
with one unit of one code. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
We looked at the file and Medicare rules. The documentation supports that this panel used the nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or multiple kits were 
used in this case. As such, a single code with one unit of service should be used. Based on this information, we 
decided that Medicare rules for coverage of the testing panel have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab panel provided on September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on June 02, 
2023, to June 12, 2023. 
 
You asked the Plan to waive the copayment for an acute inpatient stay. You say that you should not be charged 
for this service as you were inpatient again within 2 days. 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 $345 
copayment for inpatient hospital care. 
 
You have been asked to pay a $345 copayment for an acute inpatient stay. This item/service falls within the inpatient hospital 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. You have been asked to pay a total of $1,725 for the inpatient hospital stay ($345 
copayment x 5 days = $1,725). You have not been charged for the day you were discharged. Therefore, we 
decided that the Plan does not have to waive the copayment for an acute inpatient stay provided on June 02, 
2023, to June 12, 2023.