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

 
We decided that the Plan has to pre-approve a CT brain blood flow analysis (0042T). 
 
You asked the Plan to pre-approve a CT brain blood flow analysis. You say that the enrollee needs a CT brain 
blood flow analysis. The Plan denied your request. The Plan says that rules for a CT brain blood flow analysis 
have not been met. 
 
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 brain blood flow analysis. Our 
reviewer says that the enrollee needs this medical service. Our physician reviewer found that, according to 
current guidelines from the American College of Radiology, the use of CT perfusion imaging is indicated for: 
"To assist in planning and evaluating the effectiveness of therapy for cervical or intracranial arterial occlusive 
disease (as an isolated test or in combination with a cerebrovascular reserve challenge) and/or chronic cerebral 
ischemia." Given that the study is being done in accordance with current guidelines it can be considered to be 
reasonable and necessary and therefore eligible for coverage. 
 
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 brain blood flow analysis have been met. Therefore, we decided that the 
Plan has to pre-approve a CT brain blood flow analysis (0042T).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core build up (D2950). 
 
You asked the Plan to pre-approve the dental service. You say that your dentist advised that the core build up 
may not be necessary. You say that you will not know until the dentist can determine how much tooth structure 
is remaining. You also say that that your dentist advised there are no other codes that can be billed instead. The 
Plan denied your request. The Plan says core build up is not listed as a covered 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core build up (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiation therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that proton beam therapy is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says the requested services are available from in-network providers.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approveradiation therapy services to be provided by an outof network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services could be safely received in other settings, such as: a skilled nursing facility, 
home with home health and home physical therapy, or home with outpatient therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no identified problems that 
need inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea genicular block for knee pain.You asked the Plan to pre-approvedestruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624). You say that the genicular blocks give the enrollee pain relief.The Plan denied your request. The Plan says medical studies haven't proven that the procedure is helpful for treatment of the enrollee's health problem.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 destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational procedure that is the subject of on-going clinical trials. Therefore, the request is considered not medically reasonable or 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 destructionby neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624) have not been met.Therefore, we decided that the Plan does not have to pre-approvea genicular block for knee pain.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (99601) provided on April 20, 2020. 
 
You asked the Plan to pay for home infusion therapy. You say that this denied in error. The Plan denied your 
request. The Plan says this code is not valid for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status 
indicator of ?I.? Medicare uses another code for reporting of, and payment for these services. Based on this 
information, we decided that Medicare rules for coverage of home infusion therapy have not been met. 
Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided on April 
20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames and lenses (V2020 and V2201) provided on April 24, 
2020. 
 
You asked the Plan to pay for the frames and lenses. You say that you would like reconsideration because your 
glasses were broken beyond repair. The Plan denied your request. The Plan says there is a limited benefit for 
eyeglasses which has already been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers a $125 allowance for eyeglasses every 24 months.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames and lenses have not been met. Specifically, the record indicates that your limited benefit 
 
 
for eyeglasses has been exhausted. Therefore, we decided that the Plan does not have to pay for frames and 
lenses (V2020 and V2201) provided on April 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp 
removal you had at an outpatient hospital facility on May 13, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy. You say that this surgery was approved so it 
should be paid in full. The Plan denied your request. The Plan says you were charged this copayment 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 hospital services.  
 
You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the 
outpatient hospital 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 the 
diagnostic colonoscopy with polyp removal you had at an outpatient hospital facility on May 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive 
the coinsurance for a Medicare Part B drug provided on May 11, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare 
Part B drug. You say that the doctor gave you the injection in the wrong leg. 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 $45 
copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You had a specialist visit on May 11, 2020. Therefore, you are responsible to pay the $45 copayment.  
 
You received a Medicare Part B drug on May 11, 2020. The allowed amount is $910.80 and 20% of that is 
$182.16.  
 
The total amount you owe is: $227.16.  
 
You have been asked to pay the total amount of $227.16 for a specialist visit and a Medicare Part B drug. A 
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. 
A Medicare Part B drug 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. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a 
Medicare Part B drug provided on May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services rendered on May 21, 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 procedure code J0702 is not supported. 
 
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 J0702 is injection, betamethasone acetate 3 mg and 
betamethasone sodium phosphate 3 mg. 
 
We find that CPT code J0702 is not supported in the medical record. Specifically, the documentation does not 
support the billed units of betamethasone 3 mg and betamethasone sodium phosphate 3 mg injections. 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 injection services rendered on May 21, 2020.
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 a LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
coverage of a LTACH admission. 
 
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 the patient in this case has a history of uterine cancer status post chemotherapy 
who was admitted to the current acute care facility for evaluation of a small bowel obstruction and sepsis. She 
was treated with conservative management including pain medication, antibiotics, a percutaneous endoscopic 
gastrostomy (PEG) tube, rectal tube, and abdominal drain. The course was complicated by leg deep vein 
thrombis (DVT), and abscess treatment. Hospice was recommended due to poor prognosis. The patient appears 
to have better managed with conservative care at this time, but requires an additional short term stay in the 
acute care hospital (less than 25 days) to stabilize, which can be safely completed at the current facility. The 
patient does not require services at the LTACH that are not already available at the current facility. There are 
no services at the LTACH that the patient requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a 
lower level of care may be considered soon for ongoing comfort/conservative treatments. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVyzulta.You asked the Plan to pre-approveVyzulta. You say that the enrollee needs treatment with Vyzulta.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugrequested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveVyzulta.Benefits for Vyzultamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the general health panel you received on July 2, 2020. 
 
You asked the Plan to pay for the general health panel. You say that the doctor wanted you to have this testing 
done. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by 
Medicare. However,  
 
You have requested payment for a GHP, billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, the Plan does not have to pay for the GHP billed under code 80050. 
Therefore, we decided that the Plan does not have to pay for the general health panel you received on July 2, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on March 12, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the chest x-ray. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says you did not request prior authorization and the services were not urgent or 
emergent. 
 
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 chest x-ray provided on March 12, 2020 by an 
out of network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 25, 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 screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on June 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on October 29, 2019, 
through December 31, 2019. 
 
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this provider is a non-certified Medicare 
provider. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The provider in question does not participate in the Medicare 
program and therefore is not payable for these services. 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 the home health services provided on October 29, 2019, through December 31, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health services you 
received from May 16, 2020, to July 10, 2020. 
 
You asked the Plan to waive the copayments for the outpatient mental health services. You say that you did not 
understand about these copayments because you thought these services would be covered. The Plan denied 
your request. The Plan says you were charged these copayments 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 $10 
copayment for outpatient mental health care visits with a specialist.  
 
You have been asked to pay a $10 copayment for each of the outpatient mental health services you received. 
This copayment is the same regardless of whether or not the provider is in-network or out-of-network. 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 copayments for outpatient mental health services you received from May 
16, 2020, to July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 12, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that information was 
misrepresented when you signed up with the Plan and cannot afford all the charges. 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's 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 a specialist visit provided on February 12, 2020.  
 
We note your complaint that you were misled when signing up with the Plan. Your complaint is a grievance 
that must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.