Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on June 8, 2023. 
 
You asked the Plan to pay for the psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the provider must attempt to consult the attending or primary care physician 
about the services furnished and document the consent or declination date to consultations, and the date of 
consultations in the patients medical record. There was no documentation of contact in the patient record. 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 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 psychotherapy provided on June 8, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 27, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services 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 laboratory services 
provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for durable medical equipment codes E0118 and E0676 billed 
for date of service August 10, 2023. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says there is 
insufficient literature demonstrating safety and effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and the rules. Claims for E0676 will be statutorily denied as no Medicare benefit. There is 
insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to 
establish the medical necessity for code E0118. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
durable medical equipment codes E0118 and E0676 billed for date of service August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0009 billed for date of service June 27, 
2023. 
 
You asked the Plan to pay for the billed service. You say that the procedure is coded appropriately. The Plan 
denied your request. The Plan says the revenue code was incorrectly billed. 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 looked at the file and the rules. Although the service at issue was billed with the correct revenue code, 
Costs for the influenza virus or pneumococcal pneumonia vaccines are included in the cost report. Based on 
this information, we decided that Medicare rules for coverage of the billed service have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code G0009 billed for date of service 
June 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an external amulatory infusion pump 
provided on July 03, 2023. 
 
You asked the Plan to waive the coinsurance for an external amulatory infusion pump. You say that you should 
not have to pay for this item at all. You need it for your on-going issues, making it medically necessary. 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 durable medical equipment (DME) and related supplies. 
 
You have been asked to pay 20% coinsurance for an external amulatory infusion pump. This item/service falls 
within the durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $1,100.95 ($5,504.73 x 20% 
= $1,100.95). Therefore, we decided that the Plan does not have to waive the coinsurance for an external 
amulatory infusion pump provided on July 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on June 22, 2023. 
 
You asked the Plan to pay for the definitive UDT for 22 or more drug classes. You say that the toxicology drug 
screen provides valuable information for physicians to use in determining the appropriate medication at the 
appropriate dosage determined by genetic-based testing. The Plan denied your request. The Plan says the 
number of definitive urine drug classes requested are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that definitive UDT is covered when the criteria in the 
rules section of this letter 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 pay for the definitive UDT for 22 or more drug 
classes. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the 
medical record sent by the provider shows a definitive UDT panel for multiple drug classes was performed but 
does not show screening test results which are positive or inconsistent with prescription medications, dosing 
schedules, or history and expected results. The review has determined that the enrollee does not meet the LCD 
criteria for coverage. 
 
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 definitive UDT for 22 or more drug classes have not been met. Therefore, 
we decided that the Plan does not have to pay for the definitive urine drug testing (UDT) for 22 or more drug 
classes (G0483) provided on June 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of Kerecis skin substitute (15271, Q4158). 
 
You asked the Plan to pre-approve placement of Kerecis skin substitute. You say that the requested services are 
a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 placement of Kerecis skin substitute. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the provided records in this case do not clearly show all underlying 
conditions or exacerbating factors have been controlled for and any nidus of infection or colonization with 
bacterial or fungal elements and elimination of underlying cellulitis have been achieved to meet criteria for the 
skin substitute. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of placement of Kerecis skin substitute have not been met. Therefore, we decided 
that the Plan does not have to pre-approve placement of Kerecis skin substitute (15271, Q4158).
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 you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says you do not meet the requirements for approval.  
 
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 medical records provided you would be expected to participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility, however the 
medical records do not support a complexity of needs to require an acute inpatient rehabilitation facility over a 
skilled nursing facility.  
 
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 waive the copayment for remote monitoring provided on June 30, 
2023, to August 31, 2023. 
 
You asked the Plan to waive the copayment for remote monitoring. You say that you were never told there 
would be copayments for the provider looking at your information remotely. 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 $5 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $5 copayment for remote monitoring. 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 $15 ($5 copayment x 3 
services = $15 total). Therefore, we decided that the Plan does not have to waive the copayment for remote 
monitoring provided on June 30, 2023, to August 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 21, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. 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, for 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 provided on February 21, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0296). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this bed is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed (E0296).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 01, 2023. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 an office visit provided 
on August 01, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services described by code 
99223 billed for date of service August 8, 2022. 
 
You asked the Plan to pay for 99223. You say that 99223 should be paid as billed because it is supported in the 
documentation. The Plan denied your request. The Plan says 99223 is denied because it is not supported in the 
documentation. 
 
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 99223 is not supported in the medical record. Specifically, the case file does not contain 
any evaluation and management notes for the billed date of service August 8, 2022. The only records provided 
have the encounter date listed as August 6, 2022. Based on this information, we decided that Medicare rules for coverage of 99223 have not been met. Therefore, we decided that the Plan does not have to pay for the 
evaluation and management services described by code 99223 billed for date of service August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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. 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 pre-approve a ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found although the enrollee has chronic 
obstructive pulmonary disease (COPD) and chronic respiratory failure, there is no documented failure of 
bilevel positive airway pressure (BIPAP) therapy. Best practice would be a trial of BIPAP, and documentation 
does not support a home ventilator at this time. Hence, no indication for home ventilator. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on March 29, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that this testing was medically necessary. 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 the laboratory services 
provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires care in the LTACH 
and cannot go to a lower level of care. The Plan denied your request. The Plan says that the LTACH services 
requested do not meet the requirements for approval. 
 
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 considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is being managed for osteomyelitis with a complicated wound of their left foot. 
The enrollee will be receiving intravenous antibiotics for several more weeks and their need for inpatient level 
services will likely meet or exceed 25 additional days. The enrollee also has end-stage renal disease and 
requires dialysis. The enrollee's care provider has attested that the enrollee's needs will not be met by the health 
care setting being offered by the Plan, and that the enrollee will be at "high risk for loss of limb, sepsis, septic 
embolism, septic shock and/or death" unless care is given at an LTACH. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve long term acute care hospital (LTACH) services.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to fuse the lower spine. 
 
You asked the Plan to pre-approve surgery to fuse the lower spine. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says you do not meet the 
requirements for approval. 
 
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 surgery to fuse the lower spine. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the diagnostic imaging studies and exams do not corroborate any 
significant pathologies at these levels to require stabilization procedures. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested L2-3 posterior interbody fusion, T10-L3 posterior spinal fusion, L2-3 laminectomy, 
and instrumentation T10-S1 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 surgery to fuse the lower spine have not been met. Therefore, we decided that 
the Plan does not have to pre-approve surgery to fuse the lower spine.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81450). 
 
You asked the Plan to pre-approve genetic testing. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the provided records do not support the requested 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 genetic testing have been met. Specifically, the provided documentation does not sufficiently identify the requested genetic testing. Therefore, 
we decided that the Plan does not have to pre-approve genetic testing (81450).