Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
September 6, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you should have a $0 
copayment for the office visit. 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 $20 
copayment per specialist in-person visit.  
 
You have been asked to pay a $20 copayment for the specialist office visit. 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the specialist office visit provided on September 6, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the face, 
orbit, neck and head before and after contrast. 
 
You asked the Plan to pre-approve the MRI scans. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the records do not show a detailed eye exam that supports further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI scans. Our reviewer says that 
the MRI is not medically necessary. Our physician reviewer found there is insufficient supportive clinical 
information provided such as a detailed eye examination or any other evidence of a problem with the optic 
nerve, growth in eye area, or other indication for advanced imaging at this time. Therefore, the MRI will be 
considered not medically necessary 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 the MRI scans have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the face, orbit, neck and head before and 
after contrast.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing billed for date of service September 14, 2022. 
 
You asked the Plan to pay for the billed testing. You say that best practices support the use of WATS. The Plan 
denied your request. The Plan says screening for Barrett's esophagus is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that WATS testing was provided. 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 billed testing. Our physician reviewer found that WATS testing is not standard of care and therefore, not 
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 the billed testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the lab testing billed for date of service September 14, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on December 31, 2022, to 
January 5, 2023, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
claim was accurately billed with the appropriate DRG. The Plan denied your request. The Plan says that the 
medical records did not have sufficient documentation to clinically validate the diagnosis of J96.21 (acute and 
chronic respiratory failure with hypoxia). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code J96.21 defined as acute 
and chronic respiratory failure with hypoxia. 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 
inpatient hospital services at the DRG originally billed. Our physician reviewer found that the patient presented 
with several days of shortness of breath (an acute change), desaturations to 87% on 3 liters per minute (LPM) 
of oxygen and 88% on 4 LPM, as well as an increase in her respiratory rate. The medical records support 
secondary diagnosis code J96.21. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the 
inpatient hospital services provided on December 31, 2022, to January 5, 2023, at the Diagnosis Related Group 
(DRG) originally billed.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on November 20, 2022, 
to November 27, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the 
medical records support the billing of diagnosis A41.89 (other unspecified sepsis), so the original DRG billed 
should be paid. The Plan denied your request. The Plan says he billed principal diagnosis of A41.89 (other 
unspecified sepsis) is not supported by the medical record. There is insufficient evidence of sepsis in the 
medical records, so a lower DRG was paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with a principal diagnosis of A41.89 (other unspecified 
sepsis). 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 inpatient hospital services at the DRG 
originally billed. Our reviewer says that the billed principal diagnosis of A41.89 (other unspecified sepsis) is 
not supported by the medical record. Our physician reviewer found the enrollee is a 71-year-old female who 
was  treated in the hospital for influenza and Campylobacter enteritis initially treated with antibiotics and 
fluids. Workup, evaluation and monitoring throughout the hospital stay revealed a normal mental status at her 
baseline, no hypoxia, no hypotension, normal bilirubin, and no significant oliguria, although creatinine was 
elevated initially, and improved with fluids. Also, thrombocytopenia was noted as directly related to 
chemotherapy use and didn't change acutely. There was insufficient evidence of the patient experiencing organ 
failure directly related to a dysregulated response to infection. Sepsis-3 criteria is not met. Therefore, the code, 
A41.9 (sepsis) is not supported for this admission.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided on November 20, 2022, to November 27, 2022, at the Diagnosis 
Related Group (DRG) originally billed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a microprocessor knee for a lower-limb prosthesis. 
 
You asked the Plan to pre-approve a microprocessor knee. You say that the request is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says the requested knee 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 a microprocessor knee. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the documentation does not support that a microprocessor knee is required. There is no 
indication the enrollee has previously failed treatment with a mechanical knee. 
 
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 microprocessor knee have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a microprocessor knee for a lower-limb prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nebulizer provided on July 1, 2023, by an OON provider.  
 
You asked the Plan to pay for the nebulizer. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this item is not covered when received by an out-of-
network provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has a POS option to use either network providers or out-of-network providers for certain 
covered services. The Plan contract also says that out-of-network durable medical equipment is not covered. 
 
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 this item. Therefore, we 
decided that the Plan does not have to pay for the nebulizer provided on July 1, 2023, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the nerve block injections provided on 
July 14, 2023, and July 25, 2023, and the nerve destruction procedure provided on August 8, 2023. 
 
You asked the Plan to waive the copayments for the injections and the nerve destruction procedure. You say 
that you did not know that there would be outpatient surgery costs. 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 $325 
copayment for each Medicare-covered outpatient surgery, including services provided at hospital outpatient 
facilities.  
 You have been asked to pay a $325 copayment for the injections and the nerve destruction procedure. You 
have been asked to pay a total of $975 ($325 copayment x 3 visits = $975). These services fall within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 the nerve block injections provided on July 14, 2023, and July 25, 
2023, and the nerve destruction procedure provided on August 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 21, 2023, by an OON 
provider.   
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says this service was not authorized. 
 
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 this service. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on September 21, 2023, by an OON 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulation provided on August 10, 2023. 
 
You asked the Plan to pay for chiropractic manipulation. You say that this was medically necessary and should 
be covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for chiropractic 
manipulation provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA testing (81479) provided on March 22, 2023. 
 
You asked the Plan to pay for the PrismRA testing. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of the PrismRA Molecular Signature 
test in the setting of inflammatory arthritis have not been demonstrated in the peer-reviewed literature 
 
The Plan follows Medicare rules. Medicare rules say that this testing 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 PrismRA testing. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found that PGx testing is not covered when a treating clinician is not considering treatment with a medication that has an actionable drug-gene interaction, or 
when the use of a medication with a drug-gene interaction is not reasonable and necessary. The clinical value 
and effectiveness of the PrismRA Molecular Signature test in the setting of inflammatory arthritis have not 
been demonstrated in the peer-reviewed literature. 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 PrismRA testing have not been met. Therefore, we decided that the Plan 
does not have to pay for the PrismRA testing (81479) provided on March 22, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on May 30, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were 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 psychotherapy provided 
on May 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical stimulation device (E0766). 
 
You asked the Plan to pre-approve an electrical stimulation device. 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 tumor treatment field therapy (E0766) 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 an electrical stimulation device. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found Medicare criteria 
require the enrollee to have been using the device on average 18 hours per day and for newly diagnosed 
glioblastoma. However, the enrollee's recent magnetic resonance imaging (MRI) from last month (November 
10, 2023) shows progression of the cancer suggesting lack of benefit with prior use of Optune. Also, the 
documentation does not show the enrollee has a glioblastoma. Also, the enrollee has recurrent disease. 
Therefore, based on the provided documentation, this enrollee does not meet criteria for use of this device at 
this time. 
 
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 electrical stimulation device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an electrical stimulation device (E0766).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve minimally invasive lumbar decompression (MILD). 
 
You asked the Plan to pre-approve MILD. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records show the enrollee had a MILD in the lumbar region on August 
3, 2023. The Plan also says that a MILD during the past 12 months is an exclusion for the clinical study. 
 
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 MILD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested MILD procedure is experimental and investigational. There is more research 
needed to show efficacy. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MILD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve minimally invasive lumbar decompression (MILD).
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 of denied 
authorization. The Plan denied your request. The Plan says the coverage criteria has not been met.  
 
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 complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy in an 
intensive rehabilitation therapy program. Medically necessary care can be provided in a different level of care. 
There is no reasonable expectation that the enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF.  
 
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 pre-approve an out-of-network referral for computed tomography 
angiography (CTA) of the abdomen, pelvis, heart, and arteries. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the service is available with a provider 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 out-of-network referral for computed tomography angiography (CTA) of the abdomen, pelvis, heart, and 
arteries.