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

 
We decided that the Plan does not have to pay for Guardant 360 Liquid CDx (0326U) billed for date of service 
October 16, 2022. 
 
You asked the Plan to pay for Guardant 360 testing. You say that this test was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this claim was submitted with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that generally, laboratory services should be reported 
with the date of specimen collection as the date of service. However, there are a few exceptions to this rule.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant 360 testing have not been met. Specifically, the records show that the sample in this case is a liquid/blood sample, which means that none of the possible date of service exceptions apply. This claim 
should be submitted with the date of specimen collection as the date of service. The record shows that the 
sample for this test was collected on October 3, 2022. Therefore, we decided that the Plan does not have to pay 
for Guardant 360 Liquid CDx (0326U) billed for date of service October 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a lightweight wheelchair, and armrests 
provided on April 27, 2022, to July 27, 2022. 
 
You asked the Plan to waive the coinsurance for a lightweight wheelchair, and armrests. You say that you were 
not told that this was a rental. 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 a lightweight wheelchair, and armrests. 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 $47.22 ($236.26 
allowed amount x 20% = $47.22 rounded down). Therefore, we decided that the Plan does not have to waive 
the coinsurance for a lightweight wheelchair, and armrests provided on April 27, 2022, to July 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 30, 2023. 
 
You asked the Plan to pay for a home visit. You say that the provider was not responsible for obtaining 
authorization. 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 a home visit provided on 
March 30, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound study provided on April 17, 
2023. 
 
You asked the Plan to waive the copayment for an ultrasound study. You say that you did not know why you 
were having the test. 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 $95 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $95 copayment for an ultrasound study. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that the Plan does not have 
to waive the copayment for an ultrasound study provided on April 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 21, 
2023, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a 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 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 item/service 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/service. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 21, 
2023, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the facet joint injections provided on October 18, 2022. 
 
You asked the Plan to pay for  the injections. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says the facet joint injections are 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 injections. Our reviewer says that that 
the enrollee did not meet the LCD coverage criteria. Our physician reviewer found that there is documentation 
of radiculopathy, post laminectomy syndrome, spondylosis, and myofascial pain and myalgia that could 
explain the source of the enrollees pain. Therefore, the procedure 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pay for  the facet joint injections provided on October 18, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone CYP 200mg/ml. 
 
You asked the Plan to pre-approve Testosterone CYP 200mg/ml. 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Testosterone CYP 200mg/ml. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Food and Drug 
Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare 
approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's 
clinical situation. The provided records are insufficient to establish that the enrollee has a diagnosis for which 
coverage is available under the rules. The elements of the coverage criteria are not satisfied. The requested 
service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Testosterone CYP 200mg/ml have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Testosterone CYP 200mg/ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional 48 trips. 
 
You asked the Plan to pre-approve the additional 48 trips. You say that you are trying to schedule a same day 
ride. You say you are diabetic and needs to be seen every three months. The Plan denied your request. The Plan 
says the benefit has been exhausted. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional 48 trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 27447 billed for date of service December 1, 2022. 
 
You asked the Plan to pay for code 27447. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says code 27447-LT is not supported by the medical record. 
The submitted medical records do not indicate that lateral compartment of the knee was replaced. 
 
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 code 27447 is Arthroplasty, knee, condyle and plateau; medial 
and lateral compartments with or without patella resurfacing (total knee arthroplasty). 
 
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 code 27447. Our reviewer says that code 27447 is not 
supported by the medical record. Our reviewer found the medical records provided indicate that an Arthroplasty, of the knee was performed, however, there is not sufficient documentation to validate that the 
lateral compartment of the knee was replaced, which is part of the description of CPT 27447, therefore this 
procedure cannot be verified.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 27447 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 27447 billed for date of service December 1, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have 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 would benefit from 
admission to an LTACH to regain maximum/prior level of functioning and continue a multidisciplinary 
approach to care. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
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 not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee appears to still be somewhat unstable and requires additional short-
term acute care services that can safely be completed at the current facility until more stable and appropriate for 
transfer. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH would not be clinically advantageous at this time and 
completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing evaluation provided on December 13, 2022, by 
an OON provider.  
 
You asked the Plan to pay for the hearing evaluation. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the hearing evaluation provided on December 13, 
2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT) (77373). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary. The Plan denied your 
request. The Plan says that there is no good evidence the SBRT treatment is safe or effective for the enrollee's 
cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found for metastatic disease, SBRT is generally indicated for enrollees with oligometastatic disease or 
for those undergoing palliation after prior radiation to the same site. Oligometastases are defined as a state of 
metastatic disease with metastases few in number and extent. For this enrollee, there is only one site of 
metastasis which is to be treated with radiotherapy. The benefit of SBRT perhaps remains controversial, 
particularly in light of the recent negative Neuromuscular Research Group (NRG) BR002 study that showed no 
benefit with respect to progression free survival in women treated with standard of care systemic therapy with 
or without SBRT for breast cancer oligometastases to any site. In summary, despite mixed data, based on 
consensus guidelines, SBRT would be considered to be furnished in accordance with accepted standards of 
medical practice. As such, the decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
Stereotactic Body Radiation Therapy (SBRT) (77373).  
 
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 the Vertiflex procedure. 
 
You asked the Plan to pre-approve Vertiflex. You say that this surgery will help you feel better and is needed 
for your quality of life. The Plan denied your request. The Plan says there is insufficient evidence of efficacy. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex procedure is experimental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided from February 3, 2023, to 
February 5, 2023. 
 
You asked the Plan to pay for the medical services. You say that you have provided medical records to support 
payment. The Plan denied your request. The Plan says you billed an incorrect Place of Service code on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must bill the appropriate POS code for 
services.  POS code 21 indicates that the services were performed in an inpatient hospital setting. POS code 22 
indicates that the services were performed in an outpatient hospital setting. 
 
In this case, you billed the claim for these services with POS code 21.  However, the documentation shows that 
the patient was in an observation status.  Observation is an outpatient status, so POS code 22 should have been 
used on the claim instead.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay 
for medical services provided from February 3, 2023, to February 5, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the MBBs (64493, 64494). 
 
You asked the Plan to pre-approve the MBBs. You say that the enrollee needs the injection to improve their 
condition. The Plan denied your request. The Plan says the injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that MBBs are covered when the criteria listed in the 
Medicare rules section 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 the MBBs. Our reviewer says that the 
coverage criteria have been met. Our physician reviewer found that the physical exam does not show 
radiculopathy. The enrollee has clear facet disease, and it is medically reasonable and necessary to perform 
diagnostic blocks. 
 
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 MBBs have been met. Therefore, we decided that the Plan has to pre-
approve the MBBs (64493, 64494).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the remote monitoring services provided on January 18, 
2023, by an OON provider.  
 
You asked the Plan to pay for the monitoring services. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
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 the remote monitoring services provided on 
January 18, 2023, by an OON provider.