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

 
We decided that the Plan does not have to waive the copayment for the cataract surgery provided on March 23, 
2023. 
 
You asked the Plan to waive the copayment for the cataract surgery. You say that a film grew on your eye after 
a previous procedure. 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 $275 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $275 copayment for the cataract surgery. This item/service falls within the in-
network outpatient surgery provided at an ambulatory surgical center 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 cataract surgery provided on March 23, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 27, 2022. 
 
You asked the Plan to pay for laboratory services. You say that prior authorization was obtained to perform the 
services rendered. 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 December 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a trial spinal cord stimulators to be provided by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a trial spinal cord stimulators to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide these services. Therefore, coverage criteria have not been met. 
 
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 
a trial spinal cord stimulators to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 31, 2023. 
 
You asked the Plan to pay for the physician's services. You say that the assisted living facility is responsible to 
obtain prior authorization for their patients, which should cover the medical treatments with this provider. The 
Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 
require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for physician's services provided on January 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on January 20, 
2023. 
 
You asked the Plan to pay for the DecisionDx-SCC test. You say that this testing is medically necessary. The 
Plan denied your request. The Plan says this testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that molecular diagnostic laboratory tests are subject 
to the MolDX application, assessment, and approval process. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as not covered. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC test have not been met. 
Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC test (0315U) provided on 
January 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Proton Beam Treatment (PBT) with 41 fractions. 
 
You asked the Plan to pre-approve PBT. You say that the treatment is medically necessary for the enrollee. The 
Plan denied your request. The Plan says there is not enough medical evidence to show that this type of 
radiation treatment is more effective or has less side effects than other forms of radiation therapy for prostate 
cancer. 
 
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 PBT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. Nothing in the case file suggests that standard dosimetric constraints 
cannot be met with a non-proton-based treatment, and it is not plausible that proton therapy would be needed to 
meet these constraints. Proton therapy will almost always reduce dose to surrounding normal tissues. Simply 
demonstrating that proton therapy will reduce the low dose to normal tissues does not necessarily demonstrate 
that it is clinically needed relative to IMRT though, as the reductions should be clinically meaningful, and 
reduce toxicity risks in a clinically meaningful manner. While the National Comprehensive Cancer Network 
(NCCN) guideline consider proton therapy a reasonable alternative they do not describe it as being necessary 
in lieu of non-proton-based treatment and are quite explicit in that there is no evidence of its superiority. The 
decision is unfavorable as our reviewer does not believe the LCD criteria are 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 PBT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Proton Beam Treatment (PBT) with 41 fractions.
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 enrollee is in need of inpatient rehabilitation for 
medical complexities, comorbidities and therapy needs. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99223) provided on March 7, 2023. 
 
You asked the Plan to pay for the physician services. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as 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 find that CPT code 99223 is not supported in the medical record. Specifically, the records show the patient 
was under outpatient observation, how the claim was billed with an inpatient place of service (21). Based on 
this information, we decided that Medicare rules for coverage of the physician services have not been met. 
Therefore, we decided that the Plan does not have to pay for physician services (99223) provided on March 7, 
2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure codes 87481, 87640, 87652, 
87798) rendered on December 14, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the laboratory results do not support the billing of these codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 87481: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique 
 CPT 87640: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 
 
CPT 87652: 
 
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 
 
CPT 87798: 
 
Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, 
each organism 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that CPT codes 87481, 87640, 87652, 
87798 are not supported. The documentation does not contain results for these specific tests, either stating that 
they were tested for and negative, or tested for and positive. It cannot be verified that these specific tests were 
performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services (procedure codes 87481, 87640, 87652, 87798) rendered on December 14, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (88365, 88364, 88342, 88291, 88368, 88369, 
88377, 81270, 81279, 81338, 81219, G0452) provided on January 27, 2023. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the billed codes are not separately payable. 
 
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 codes 88365, 88364, 88342, 88291, 88368, 88369, 88377, 81270, 81279, 81338, 81219, & 
G0452 are not supported in the medical record. Specifically, the codes billed are included in codes 81219, 
81338, 81270, 81279 and 81455 which were also billed. Based on this information, we decided that Medicare 
rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88365, 88364, 88342, 88291, 88368, 88369, 88377, 81270, 81279, 81338, 81219, G0452) 
provided on January 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility care provided on March 1, 2023, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the enrollee could not choose an in-network 
provider. The Plan denied your request. The Plan says this was not authorized. 
 The Plan must follow Medicare rules. Medicare rules say that Health Maintenance Organizations (HMOs) may 
offer a Point of Service (POS) option as a mandatory or optional supplemental benefit and may either require 
or waive prior authorization rules for obtaining POS services. The Plan contract says that physician/practitioner 
services require prior authorization. 
 
We looked at the file and Medicare rules. The services at issue were not authorized. Based on this information, 
we decided that Medicare rules for coverage of nursing facility care have not been met. Therefore, we decided 
that the Plan does not have to pay for nursing facility care provided on March 1, 2023, by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a transurethral waterjet ablation of prostate (0421T). 
 
You asked the Plan to pre-approve a transurethral waterjet ablation of prostate. You say that the requested 
service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that the requested 
service is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that treatment for LUTS/BPH will be considered medically 
reasonable and necessary when performed ONCE in enrollees who meet the criteria listed in the Medicare rules 
section of this letter. 
 
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 transurethral waterjet ablation of 
prostate. Our reviewer says that the requested service is medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has BPH and LUTS. The enrollee could not tolerate tamsulosin due 
to side effects. IPSS is 27. Cystoscopy shows trilobar BPH with obstruction. Prostate ultrasound shows prostate 
size of 70 gm. Maximum flow rate was 4 mL/s at time of unsuccessful voiding trial, requiring re-insertion of 
Foley catheter. The enrollee is currently catheter dependent due to retention. The requested transurethral 
waterjet ablation of the prostate is medically necessary for the enrollee and has met the coverage criteria. 
 
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 transurethral waterjet ablation of prostate have been met. Therefore, we 
decided that the Plan has to pre-approve a transurethral waterjet ablation of prostate (0421T).  
 
  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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you would like to request reconsideration of the 
denied authorization. The Plan denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not qualify for SNF coverage. The enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
appears to be at/near a plateau in function. The enrollee can complete her current course of treatment before 
being discharged to a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 services are medically necessary.  The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.  
 
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 does not require treatment by multiple therapies. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 3 sensor. 
 
You asked the Plan to pre-approve a FreeStyle Libre 3 sensor. You say that the item is necessary. The Plan 
denied your request. The Plan says the requested item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a non-adjunctive continuous glucose monitor 
(CGM) must be billed with code E2103. The rules also say that only devices reviewed by the PDAC and 
assigned code E2103 may be billed using this code.  
 We looked at the file and Medicare rules. The request at issue is for the Freestyle Libre 3 non-adjunctive CGM. 
However, this device has not been reviewed by the PDAC and has not been assigned code E2103. As such, this 
non-adjunctive CGM device is not eligible for coverage at this time. Therefore, we decided that the Plan does 
not have to pre-approve a FreeStyle Libre 3 sensor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 13, 2023, by an out-
of-network (OON) provider.  
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this 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 these items/services. 
Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 13, 2023, 
by an out-of-network (OON) provider.
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 services are medically necessary to give the 
enrollee the best chance to regain their baseline quality of life. The Plan denied your request. The Plan says the 
enrollee does not meet the criteria for admission to an IRF.  
 
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 does not require treatment by multiple therapies. 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.