Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the remaining additional PT visits are 
necessary. The Plan denied your request. The Plan says you do not meet the criteria for the remaining 
additional PT visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found you have received 22 sessions of PT. You started PT on April 12, 
2023. You are independent with mobility but continues to experience some degree of low back pain, which is 
worse with activity. Your range of motion and motor strength have not significantly changed since July 12, 
2023. Your progress has plateaued, and you can continue with a home exercise program to increase your 
endurance and manage your pain. Therefore, the 8 additional PT visits are 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2790) for tooth #2 provided on January 25, 2023. 
  
You asked the Plan to pay for the dental service. You say that you would like to be reimbursed for the dental 
services. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
there was no prior authorization that was approved, and the enrollee's primary insurance has already covered 
the service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is 
covered under the Plan's dental benefit but only when an approved pre-authorization is obtained. Therefore, we 
decided that the Plan does not have to pay for a crown (D2790) for tooth #2 provided on January 25, 2023.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Medicare Part B prescription drugs provided on May 22, 2023.

You asked the Plan pay for Medicare Part B prescription drugs. You say that you disagree with the coinsurance. 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 Medicare Part B prescription drugs.

You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls within the Medicare Part B prescription drugs 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 allowed amount for the prescription drugs is $247.96. You are being asked to pay $49.59 ($247.96 x 20% = $49.59). Therefore, we decided that the Plan does not have to pay for Medicare Part B prescription drugs provided on May 22, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on October 17, 2022, billed with 
codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 81335, 81479 and 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says panel testing should be billed 
using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
October 17, 2022, billed with codes 81225, 81226, 81227, 81231, 81232, 81240, 81241, 81291, 81306, 81328, 
81335, 81479 and 81238.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one additional unit of procedure code 93306 rendered on 
June 15, 2023. 
 
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 documentation only supports one unit of CPT 93306.  
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 93306 is "Echocardiography, transthoracic, real-time 
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral 
Doppler echocardiography, and with color flow Doppler echocardiography." 
 
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 the provided records only 
document on echocardiogram performed on June 15, 2023. The records do not support that a second service 
was performed, reasonable, or necessary in this case. 
 
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 one additional unit of procedure code 93306 rendered on June 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel testing 
provided on February 28, 2023, and billed with codes 87641, 87801, 87798, and 87481. 
 
You asked the Plan to pay for the urine PCR panel testing. You say that this testing was medically necessary.  
The Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the urine PCR panel testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) 
panel testing provided on February 28, 2023, and billed with codes 87641, 87801, 87798, and 87481.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel provided 
on June 2, 2023, and billed with codes 87481 and 87798. 
 
You asked the Plan to pay for the wound PCR panel. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing should be billed with a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the wound PCR panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the wound polymerase chain reaction (PCR) panel 
provided on June 2, 2023, and billed with codes 87481 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services provided on October 15, 2022, to 
December 7, 2022. 
 
You asked the Plan to pre-approve acupuncture services. You say that the Plan does not have a recognized 
provider in Hawaii. The Plan denied your request. The Plan says the acupuncture services were provided by an 
unqualified provider. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pre-approve acupuncture services provided on October 15, 2022, to December 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services 
provided on July 6, 2023. 
 
You asked the Plan to pay for OIVIT services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services billed are not supported. 
 The Plan must follow Medicare rules. The rules say that OIVIT is not reasonable and necessary for any 
indication. Services comprising an Outpatient Intravenous Insulin Therapy regimen are nationally non-covered 
under Medicare when furnished pursuant to an OIVIT regimen. Therefore, we decided that the Plan does not 
have to pay for Outpatient Intravenous Insulin Therapy (OIVIT) services provided on July 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 12, 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 June 12, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0012M) provided on April 19, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for Cxbladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder test have not been met. Therefore, we decided that 
the Plan does not have to pay for the Cxbladder test (0012M) provided on April 19, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy and home health skilled 
nursing. 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found you do not 
have documented skilled nursing needs. You do not have documented skilled therapy needs. You are 
functioning at a level commiserate with 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health physical therapy and home health skilled nursing.
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health care services for date of service October 21, 2022, to 
November 16, 2022. 
 
You asked the Plan to pay for the home health care services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the charges exceed Fee Schedule/maximum allowable or 
contracted/legislated fee arrangement. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied these services due to "the 
charges exceed Fee Schedule/maximum allowable or contracted/legislated fee arrangement". The 
documentation does not include an explanation on why the services exceed the Fee Schedule or maximum 
allowable fee. The documentation did not include any other explanation on why these services were denied. No 
other denial rationale was provided. The Plan did not substantiate their denial. Therefore, we decided that the 
Plan has to pay for the home health care services for date of service October 21, 2022, to November 16, 2022.  
 
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Remede device (0424T). 
 
You asked the Plan to pre-approve a Remede device. You say that the services are necessary. The Plan denied 
your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have 
not been met. 
 
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 a Remede device. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the Remede device is FDA approved and has safety and efficacy data supporting its use in 
patients with central sleep apnea, which has been diagnosed formally in this enrollee. 
 
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 Remede device have been met. Therefore, we decided that the Plan has to pre-
approve a Remede device (0424T).  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. You would like reconsideration based on the records submitted. The Plan denied your 
request. The Plan says admission to an LTACH 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 that 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 is not medically necessary as it would not 
be clinically advantageous 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on May 15, 
2023. 
 
You asked the Plan to pay for the bacterial urine culture. You say that this service was medically necessary and 
is supported in the medical record. The Plan denied your request. The Plan says this claim was not submitted 
with a diagnosis which supports the medical necessity of this service. 
 
The Plan must follow Medicare rules. Medicare rules say that there are certain diagnosis codes which support 
the medical necessity of code 87086. Any codes which are not listed are considered not medically necessary for 
code 87086. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the urine culture have not been met. Specifically, this claim was submitted with a diagnosis code which is not among those codes listed as medically necessary and appropriate for this service. Therefore, we 
decided that the Plan does not have to pay for the bacterial urine culture (87086) provided on May 15, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that this testing is covered by Medicare and was 
medically necessary. 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 May 26, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing (81479) billed for date of service April 19, 2023. 
 
You asked the Plan to pay for genetic testing. You say that you have billed the services at issue correctly. The 
Plan denied your request. The Plan says that the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, our review of the claim shows that the required unique identifier 
was reported. It is the Plan's responsibility to support its denial withy evidence. In this case, the Plan's denial is 
not supported, so we must find in your favor. Therefore, we decided that the Plan has to pay for genetic testing 
(81479) billed for date of service April 19, 2023.  
 
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.