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

 
We decided that the Plan does not have to waive the copayment for cataract surgery provided by a participating 
provider on February 25, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you think this should be 
reduced to $150. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $350 
copayment for outpatient surgery.  
 
You have been asked to pay a $350 copayment for an outpatient surgery. The correct copayment has been 
applied to the services provided. An outpatient surgery falls within the outpatient surgery 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 cataract surgery provided by a participating provider on 
February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 with full leg sleeve.
You asked the Plan to pre-approve these 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. Medicare rules say that an E0652 PCD is covered when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has bilateral lower extremity lymphedema. The occupational therapy (OT) evaluation on March 10, 2020 states that she had limitations in functional activities and decreased ability to ambulate in the community. There are only two OT visit notes in the records. There is no documentation by the therapist to support that she has tried and failed a basic pump for four weeks. The E0652 pump is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) coded E0652 with full leg sleeve.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the lumbar spine.
You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan. Our reviewer says that a CT scan of the lumbar spine is not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of a valid clinical reason for a CT scan of the lumbar spine. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the lumbar spine.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolaris prostate testing. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says that the 
testing would not change treatment management for the enrollee. 
 
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 the requested testing. Our physician 
reviewer found that the enrollee has an elevated Prostate Specific Antigen (PSA) of 5.5, and a prostate cancer 
Gleason score of 3+4=7 in 1 core. For prostate cancer, the NCCN Guidelines define low-risk group as patients 
with clinical stage T1 to T2a, Grade Group 1, and serum PSA level <10 ng/mL. This enrollee meets these 
criteria. If the patient?s life expectancy is 10 years or more, initial treatment options include: 1) active 
surveillance (preferred); 2) EBRT or brachytherapy; or 3) radical prostatectomy. Molecular tumor testing can 
be considered for these men for prognostic information independent of NCCN risk groups. Recommendations 
per the NCCN Guidelines are cover post-biopsy for NCCN very-low-, low-risk, and favorable intermediate-risk 
prostate cancer in patients with at least 10 years? life expectancy who have not received treatment for prostate 
cancer and are candidates for active surveillance or definitive therapy. Therefore, the service is reasonable and 
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 requested testing have been met. Therefore, we decided that the Plan has to 
pre-approve Prolaris prostate testing.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the requested testing. You say that your genetic testing will help your 
daughter's physician with her diagnosis. The Plan denied your request. The Plan says you do not meet the 
guidelines for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that he individual being tested must have signs or 
symptoms of breast, ovarian cancer, pancreatic cancer, or prostate cancer and meet one of the criteria. 
 
We looked at the file and Medicare rules. In this case, there was insufficient medical records that fully supports 
the medical necessity for services. Based on this information, we decided that Medicare rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic Left knee pain from osteoarthritis. The enrollee had a prior radiofrequency ablation of the genicular nerves which gave the enrollee 90% pain relief for 10 months. The requested services are considered experimental/ investigational and are the subject of on-going clinical trials. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional chiropractic visits.
You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 chiropractic services. Our reviewer says that the requested chiropractic services are not medically reasonable and necessary. Our physician reviewer found that the enrollee exhibits the same or similar complaints, findings and treatment throughout care, with no evidence that treatment cures or relieves the enrollee's complaints, that she has exhibited significant objective functional improvement or that resolution will ever occur. Treatment has long exceeded a reasonable prognosis. The chiropractic treatments are to prevent deterioration of a chronic condition. There is no evidence, from the submitted documentation, that improvement has occurred or will occur with additional chiropractic treatments. The chiropractic treatment are maintenance treatments and are not supported or allowed per Medicare guidelines. 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 chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional chiropractic visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior cervical fusion.
You asked the Plan to pre-approve the neck surgery. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the neck surgery. Our reviewer says that the requested posterior cervical fusion is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation of an adequate trial and failure of physical therapy for neck pain. More conservative measures are needed. 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 neck surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior cervical fusion.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you were attending a travel program when 
you began to feel ill and you left the room. You say that some people standing nearby asked you if they should 
call for help however you declined stating that it would pass. You stated that an emergency responder then 
arrived while you were in the restroom. You say that the responders checked your vitals and they said that they 
were all good. You say that you then declined transport to the hospital, and you signed a document which 
stated that. You received a bill from the provider, and you asked the Plan to reconsider providing coverage for 
the services. You say that you still do not know who called for the ambulance.  The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 27, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an 
out of network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 has network providers 
available who can provide 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 medical services provided on February 24, 
2020 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 from February 12, 2020 to 
March 16, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician?s services. 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 from February 12, 2020 to 
March 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 1, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the charges are too high because this was an emergency. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 for ambulance services. You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the ambulance 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. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and X-Ray examinations provided by a chiropractor on April 7, 2020.
You asked the Plan to pay for chiropractic services. You say that you were advised to see this provider and were told they would be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit and X-Ray examinations provided by a chiropractor on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2020.
You asked the Plan to pay for the testing services. You say that providing an accurate somatic mutation profile of tumors is the best way to choose the optimal therapy for the enrollee. The Plan denied your request. The Plan says coverage of comprehensive genomic profiling is limited to one test per specimen.
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 looked at the file and the Medicare rules. We find that the testing at issue has not been billed with the appropriate codes as outlined in the Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram (77065, 77061) provided on February 15,
2019.
You asked the Plan to pay for the mammogram. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not emergent or pre-approved. There were network
providers available.
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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 the mammogram (77065, 77061) provided on February 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 30, 2020.
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 the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for monitoring services provided to the enrollee on February 4, 2020 under code 93227.
You asked the Plan to pay for monitor services billed to the enrollee. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says based on the Medicare billing guidelines; the code billed (93227) has a 48-hour billing unit. This code was billed from February 1, 2020 to February 3, 2020 and then again singularly on February 4. This does not meet the required billing units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. Medicare rules say providers must submit the correct CPT codes. In this case, the MUE for CPT code 93227 is a 48-hour code. Services billed for less than 48 hours require a different code. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for monitoring services provided to the enrollee on February 4, 2020 under code 93227.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a facet joint injection provided on March 
12, 2020. 
 
You asked the Plan to waive the copayment for a facet joint injection. You say that you received a shot and 
disagree with the high copayment you are being charged. The Plan denied your request. The Plan says the 
claims were processed correctly, and you are being charged the correct amount. 
 
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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $250 copayment for a facet joint injection. A facet joint injection falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 a facet joint injection provided 
on March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on March 3, 2020 to April 5, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this whole situation is very stressful with you because of everything that has been going on. The Plan denied your request. The Plan says the correct copayment has been applied.
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 per day for days 1-5 for inpatient hospital care/inpatient hospital care. You have been asked to pay a $275 copayment per day for days 1-5 for an inpatient hospital stay. The total amount you are being asked to pay is $1,375 ($275 x 5 days = $1,375). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care/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 an inpatient hospital stay provided by a participating provider on March 3, 2020 to April 5, 2020.