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

 
We decided that the Plan does not have to pay for the portable x-ray services provided on June 05, 2023. 
 
You asked the Plan to pay for the portable x-ray services. You say that you are unable to acquire authorization 
before providing services. 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 portable x-ray 
services provided on June 05, 2023.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently 
acquired computed tomography (CT) scan (78816). 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you were informed that a PET scan is more 
accurate in diagnosing potential growth of melanoma than a CT scan, and that is why you have been receiving 
PET scans throughout the treatment and monitoring of your cancer. The Plan denied your request. The Plan 
says that your records do not show you meet criteria for the requested PET/CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says 
that the service is medically necessary. Our physician reviewer found after being on nivolumab for nearly five 
years, the plan is to take you off of treatment. As there is going to be a change in treatment plan, the request for 
a PET/CT scan is medically reasonable in this transition phase to check for disease recurrence. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) 
scan (78816).  
 
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 long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting an expedited 
reconsideration as the enrollee currently meets LTACH admission criteria. The Plan denied your request. The 
Plan says the enrollee does not meet the guidelines for care in an LTACH. 
 
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 is receiving care at the current acute care hospital that is covered by the 
Plan. There are no specific needs or additional treatments the enrollee would receive at the LTACH. 
 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee's status does not meet severity or intensity 
medical necessity criteria for a SNF level of care. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 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 admission is medically necessary for the enrollee. 
The Plan denied your request. The Plan says the enrollee's records do not show to have complex rehabilitation 
needs that require frequent evaluation by a rehabilitation physician.  
 
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 pay for the wound care supplies provided on February 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the wound care supplies. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were 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 wound care supplies provided on February 1, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on March 28, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the injection services. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 injection services provided on March 28, 2023, 
by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the breast ultrasound provided on April 27, 
2023. 
 
You asked the Plan to reduce the copayment for the breast ultrasound. You say that you believe you only have 
a $50 copayment for this service. 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 $75 
copayment for in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $75 copayment for the breast ultrasound. This item/service falls within the in-
network outpatient diagnostic tests, including ultrasounds 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 reduce the copayment for the breast ultrasound provided on April 27, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan 
denied your request. The Plan says the criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found the enrollee has had a computerized 
tomography (CT) scan of the chest, abdomen and pelvis that was performed on March 20, 2023, showing no 
signs of metastatic disease. A magnetic resonance imaging (MRI) scan of the left thigh with and without 
contrast performed on April 12, 2023, showed a decreasing size of the residual postoperative seroma with 
decreased conspicuity of thin enhancing rim. Conventional imaging with a CT scan and an MRI are able to be 
used in the current surveillance phase.  
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic pathogen testing provided on April 20, 2023, billed with multiple codes. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing is medically necessary.  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 pathogen testing 
provided on April 20, 2023, billed with codes [Please enter the denied codes at issue on this lab claim].
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an x-ray provided on May 17, 2023. 
 
You asked the Plan to reduce the copayment for an x-ray. You say that you disagree with the copayment. 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 $150 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $150 copayment for an x-ray. 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. However, since the allowed amount is less than the standard copayment, you only owe $100.57. Therefore, we decided that the Plan does not have to reduce the copayment 
for an x-ray provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 
09, 2023. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the provider did not 
administer the injection correctly, and you should not have to pay for this visit. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network specialist physician/practitioner services. 
 
You have been asked to pay a $35 copayment for the specialist office visit. This item/service falls within the 
in-network specialist physician/practitioner services 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 record shows this claim was approved and you are 
responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the specialist office visit provided on May 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
November 27, 2022, to November 29, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not have the 
funds to pay. 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 $225 
copayment per day, for days 1-7, for inpatient hospital care. 
 
 
 You have been asked to pay a $450 copayment for the inpatient hospital stay ($225 copayment x 2 days = 
$450). This item/service falls within the inpatient hospital care 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 inpatient hospital stay provided from November 27, 2022, to November 29, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 21, 2023. 
 
You asked the Plan to pay for drug test. You say that this is the correct code used. The Plan denied your 
request. The Plan says the record does not support that 22 or more drug classes were tested for use of code 
G0483. 
 
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 G0483 is drug test(s), definitive; qualitative or 
quantitative, all sources, includes specimen validity testing, per day; 22 or more drug classes, including 
metabolites if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not include 
testing results for 22 or more drug classes. Based on this information, we decided that Medicare rules for 
coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug 
testing provided on February 21, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnesium Sulfate. 
 
You asked the Plan to pre-approve Magnesium Sulfate. The Plan denied your request. The Plan says that the 
request is not covered under the enrollee's Part B benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Magnesium Sulfate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation provided 
by an in-network provider on March 27, 2023, and the foot x-rays, and the new patient office visit provided by 
an in-network provider on March 30, 2023.  
 You asked the Plan to waive the copayment for the pacemaker evaluation, the x-rays, and the office visit. You 
say that you do not agree with the cost sharing. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Medicare-covered non-radiological diagnostic services, a $15 copayment for each Medicare-
covered standard x-ray service, and a $20 copayment for services from a specialist or under certain 
circumstances, treatment by a nurse practitioner, physicians assistant, or other non-physician health care 
professional in a specialists office. 
 
You have been asked to pay a $20 copayment for the pacemaker evaluation. You have been asked to pay a $15 
copayment for the x-rays. These items/services fall within the outpatient diagnostic tests and therapeutic 
services and supplies benefit category. You have also been asked to pay a $20 copayment for the office visit. 
This item/service falls within the physician/practitioner services, including doctors office visits benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation provided by 
an in-network provider on March 27, 2023, and the foot x-rays, and the new patient office visit provided by an 
in-network provider on March 30, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet the requirement for 
admission to a SNF. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care.