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

 
We decided that the Plan has to pay for the inpatient hospital care provided from April 28, 2022, to May 15, 
2022. 
 
You asked the Plan to pay for the inpatient care. You say that the claim was underpaid. You say that the 
services were medically necessary. The Plan denied your request. The Plan says that prior authorization was 
not obtained. 
 
The Plan must follow Medicare rules. Medicare rules say that when post-stabilization care is obtained from a 
non-contract provider, approval is required from the plan. However, the requirement for pre-approval does not 
apply if the Plan does not respond to a request for pre-approval within one hour. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the inpatient care have been met. Therefore, we decided that the Plan has to pay for the inpatient 
hospital care provided from April 28, 2022, to May 15, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient psychiatric admission from May 28, 2023, 
forward.  
 
You asked the Plan to pre-approve an inpatient psychiatric admission. You say that the enrollee requires 
inpatient treatment due to chronic illness and high risk of decompensation if discharged before long term 
stability is achieved. The Plan denied your request. The Plan says under Medicare guidelines, the request is not 
medically necessary.  
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric admission. Our 
reviewer says that the service is not medically necessary from May 28, 2023, forward. Our physician reviewer 
found that this enrollee did not appear to require inpatient mental health treatment as the enrollee was not a 
danger to self or others and was cooperative with care without any aggressive behaviors. It did not appear that 
active treatment was taking place. It did not appear that the services were reasonably expected to improve the 
enrollees condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment 
plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based 
upon review the records provided for the admission of this enrollee does not meet criteria for acute inpatient 
mental health treatment as this enrollee was not shown to be a danger to self or others, no auditory or visual 
hallucinations. The enrollee is noted to be cooperative and compliant with treatment while not showing any 
aggressive behaviors. 
 
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 inpatient psychiatric admission have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an inpatient psychiatric admission from May 28, 2023, forward.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive drug testing billed with code 80307 for 
February 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that one presumptive drug testing code may be billed once 
per patient per day as indicated by the code description and should only be billed at one unit regardless of the 
provider 
 
We looked at the file and Medicare rules. The file shows that procedure code 80307 was billed and previously 
paid for the same date of service by the same provider. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the presumptive drug testing billed with code 80307 for February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for two additional units for procedure code 99458 rendered on 
November 29, 2022. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your 
request. The Plan says there was no specific rationale given for performing extra units. 
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units. 
 
The definition of CPT 99458 is "Remote physiologic monitoring treatment management services, clinical 
staff/physician/other qualified health care professional time in a calendar month requiring interactive 
communication with the patient/caregiver during the month; each additional 20 minutes (List separately in 
addition to code for primary procedure)."  
 
In this case, the MUE for CPT code 3. The MAI value for this code is 3. You billed 5 units of this code, 
exceeding the MUE. You did not provide all the required evidence showing that the excess units were actually 
provided, were correctly coded, and were medically necessary. The record shows that CPT 99457 (1 unit) and 
99458 (5 units) were billed in this case. This would indicate a service time of 120 minutes based on the code 
definitions. The record does not support this amount of time spent providing the service. Based on this 
information, we decided that Medicare rules for coverage of the additional units of 99458 have not been met.  
Therefore, we decided that the Plan does not have to pay for two additional units for procedure code 99458 
rendered on November 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 5, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that you were told this would be covered. 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 out-of-network office 
visits require prior authorization. 
 We looked at the file and Medicare rules. The office visit at issue was not authorized. Based on this 
information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit provided on December 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the would polymerase chain reaction (PCR) testing rendered 
on December 12, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that a panel cannot be unbundled and billed as individual 
components regardless of the fact that the test reports multiple individual pathogens and/or targets 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed as a single unit of 
service. Based on this information, we decided that Medicare rules for coverage of these services have not been 
met. Therefore, we decided that the Plan does not have to pay for the would polymerase chain reaction (PCR) 
testing rendered on December 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services billed with code 0241U for date of service 
January 5, 2023. 
 
You asked the Plan to pay for code 0241U. You say that this is a payable code. The Plan denied your request. 
The Plan says the claim for this molecular pathology testing did not include the required unique identifier. 
 The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of code 0241U have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services billed with code 0241U for 
date of service January 5, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect test (0012M) provided November 30, 
2022. 
 
You asked the Plan to pay for the laboratory service. You say that the evidence supporting the use of Cxbladder 
Detect as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says this service does not meet coverage requirements. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory service have not been met. Therefore, we decided that the Plan does not have to pay 
for Cxbladder Detect test (0012M) provided November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 6, 2023. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 6, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the SelectMDx testing (0339U) provided January 27, 2023. 
 
You asked the Plan to pay for  the laboratory services. You say that you are asking for this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says SelectMDx is not a covered benefit 
because this is not a test which has met the coverage criteria.   
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for  the SelectMDx testing (0339U) provided January 27, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Cxbladder test (0013M) provided November 7, 2022. 
 
You asked the Plan to pay for  the genetic testing. You say that the evidence supporting the use of Cxbladder 
Monitor as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says peer reviewed medical literature has not demonstrated the analytical 
validity and clinical utility outcomes of Cxbladder; therefore, Cxbladder tests are considered experimental/ 
investigational. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for  
the Cxbladder test (0013M) provided November 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services provided on January 11, 2023, billed with 
code 76706. 
 
You asked the Plan to pay for the testing services provided. You say that the claim was billed correctly and 
should be paid. The Plan denied your request. The Plan says the procedure is not supported by the diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the testing services provided have been 
met. Specifically, no medical records for this date of service have been provided for review. Therefore, we 
decided that the Plan does not have to pay for testing services provided on January 11, 2023, billed with code 
76706.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit, X-Rays, and mechanical/electrical therapy. 
office visit, X-Rays, and mechanical/electrical therapy provided on January 5, 2023. 
 
You asked the Plan to pay for office visit, X-Rays, and mechanical/electrical therapy. office visit, X-Rays, and 
mechanical/electrical therapy. You say that the services were in-network and should be covered. The Plan 
denied your request. The Plan says the cost-sharing amount you have been charged is correct. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine.  Therefore, we decided that 
the Plan does not have to pay for office visit, X-Rays, and mechanical/electrical therapy. office visit, X-Rays, 
and mechanical/electrical therapy provided on January 5, 2023.
Appeal type: Step-Therapy
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that Ilumya is a medical necessity for the enrollee. The 
Plan denied your request. The Plan says that step-therapy rules for coverage of Ilumya have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Ilumya. Our reviewer says that Ilumya 
is medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of 
3 of 4 alternative drugs (Humira, Enbrel, Cosentyx or Skyrizi) before they will approve the requested drug. 
However, step therapy may only be applied to new prescriptions or administrations of Part B drugs for 
enrollees that are not actively receiving the affected medication. The provided records document that the 
enrollee in this case has been receiving Ilumya injections since Spring 2021 through a drug assistance program. 
The Plan stated that their coverage criteria did not recognize treatment through a drug assistance program as an 
adequate exception to its step therapy rules. However, Medicare's rules do not specifically exclude treatment 
through a drug assistance program in its step therapy rules. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have been met. Therefore, we decided that the Plan has to pre-approve 
treatment with Ilumya (J3245).  
 
  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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mental health intensive outpatient program.  
 
You asked the Plan to pre-approve the mental health intensive outpatient program. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the mental health intensive outpatient 
program have been met. There were insufficient medical records submitted to determine the necessity of this service.. Therefore, we decided that the Plan does not have to pre-approve the mental health intensive 
outpatient program.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the acupuncture treatments (97810, 97811) provided 
on January 18, 2023.  
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you do not 
meet criteria for coverage of the services provided.  
 
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, the Plan has stated that you do not meet criteria for coverage of the 
services provided in this case as the acupuncture benefit is only for the treatment and diagnosis of chronic low 
back pain. However, the Plans contract states that ten acupuncture visits are covered per year for all other 
diagnoses. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to issue reimbursement for the acupuncture treatments (97810, 97811) provided on 
January 18, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the anesthetic agent injection provided on 
November 22, 2022. 
 
You asked the Plan to waive the copayment for the anesthetic agent injection. You say that you have not had to 
pay this amount for this service in the past. 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 $300 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $300 copayment for the anesthetic agent injection. This item/service falls within 
the outpatient surgery provided at an outpatient hospital 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. According to Medicare the procedure (code 64450) is 
considered outpatient surgery. Therefore, we decided that the Plan does not have to waive the copayment for 
the anesthetic agent injection provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on December 08, 2022. 
 
You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration for the services 
provided. 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 outpatient visit provided 
on December 08, 2022.