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

 
We decided that the Plan does not have to waive the copayment for the visit you had with a hospitalist on 
August 16, 2020. 
 
You asked the Plan to waive the copayment for the hospitalist visit. You say that you saw the doctor who was 
on call, so you don't think you should have to pay a specialist copayment. 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the hospitalist visit. Hospitalists are not primary care 
physicians, so they are considered specialists. The hospitalist visit falls within the specialist 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 visit you had with a hospitalist on August 
16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the charges should 
be waived due to the pandemic. 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 $40 
copayment for specialist visits.  
 
You have been asked to pay a $40 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the clinical information sufficiently justifies 
the appropriate level of subacute rehabilitation. You say that the enrollee does need daily skilled therapy to 
hasten his progress to a safe discharge home. The Plan denied your request. The Plan says the clinical 
information received does not show that the enrollee meets the guidelines for a skilled level of care. The Plan 
says that the clinical information indicates that the enrollee's needs can be safely met at a lower 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 above 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and insulin. The enrollee had stable vital signs. The enrollee received physical therapy and 
occupational therapy in the SNF. The enrollee was at a stand-by-assist to contact-guard assist level with 
 
 
functional mobility, including gait to 60 feet with rolling walker. The enrollee required varying assist with 
activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled 
therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of 
illness or intensity of service criteria for 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341) provided on 
August 11, 2020. 
 
You asked the Plan to pay for the periodontal scaling and root planing. You say that you were not aware these 
services would not be covered. The Plan denied your request. The Plan says the benefit for these services had 
been exhausted. 
 
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. The Plan covers the 
periodontal scaling and root planing when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that you had this procedure performed in March 
2020, thereby exhausting your benefit for periodontal scaling and root planning for the 2020 and 2021 calendar 
year. Based on this information, we decided that the Plan's rules for coverage of the periodontal scaling and 
root planing have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal 
scaling and root planing (D4341) provided on August 11, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), head or brain (70450). 
 
 
You asked the Plan to pre-approve the CT scan. You say that please review the updated medical records for 
authorization request CT scan. The Plan denied your request. The Plan says that review of the medical records 
do not support that mental status tests were performed and therefore this request is not reasonable and 
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 the CT scan. Our reviewer says that the 
requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer 
found CT scan of the head is a necessary study in the diagnosis of dementia. It can differentiate vascular 
dementia and rules out space occupying lesion that may be the cause of dementia. The study is medically 
indicated and reasonable. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), head or brain (70450). 
  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Humira Pen kit. 
 
You asked the Plan to pre-approve Humira. You say that Remicade infusions are no longer working for the 
enrollee. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient 
prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve a Humira Pen kit.  
 
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided. 
 
You asked the Plan to pay for physician services provided to the enrollee. You say that this claim should be 
paid. The Plan denied your request. The Plan says code 99497 is no supported by the medical records. The Plan 
says that the records provided did not include documentation of advance care planning including the 
explanation and discussion of advance directives with face to face time spent; therefore, the billed service 
cannot be verified. It is noted that multiple attempts were made to contact the provider for additional 
information. 
 
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, based on review of the records 
provided, the information submitted does not support the services billed. Medicare billing criteria are not met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that your fiance could have 
taken you to the hospital instead of an ambulance. 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 $215 
copayment for ambulance services.  
 
You have been asked to pay a $215 copayment for the ambulance services. This copayment applies regardless 
of the reason for the transport. 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on August 18, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you thought that you would not 
owe a copayment for gynecology services and feel that the claim was coded incorrectly. 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 $20 
copayment for laboratory tests.  
 
The laboratory tests you received on August 18, 2020, are not considered a preventative service. Therefore, you 
are responsible to pay the $20 copayment.  
 
You have been asked to pay a $20 copayment for laboratory tests. Laboratory tests fall 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. Therefore, we decided that the Plan does not have to waive the 
copayment for laboratory tests provided on August 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest you had. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you should not have to pay this 
copayment because this test was ordered by your doctor. 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 $110 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $110 copayment for the CT scan. The CT scan falls within the radiological 
diagnostic services benefit category. This copayment applies even if this test is ordered by your doctor. 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 computed tomography (CT) scan of the chest you had.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you have ongoing problems getting out of 
chairs. The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above 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 services are not medically necessary. Our physician reviewer found the records do not show that you have a 
neuromuscular disease or that the seat lift mechanism would likely improve or slow deterioration of your 
condition. The records do not show that you are completely incapable of standing from a chair in the home on 
physical exam. The seat lift mechanism is therefore not reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fine needle aspiration biopsy services coded 10005 
provided on July 28, 2020. 
 
You asked the Plan to pay for the fine needle aspiration biopsy services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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. 
 
In this case, the MUE for CPT code 10005 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of the fine needle aspiration biopsy services have 
not been met. Therefore, we decided that the Plan does not have to pay for the fine needle aspiration biopsy 
services coded 10005 provided on July 28, 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 July 28, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with 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 $40 
copayment for services provided by a specialist.  
 
You have been asked to pay a $40 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 July 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on August 21, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with 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 $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall 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. Therefore, we decided that the Plan does not have to waive the 
copayment for laboratory tests provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic testing you received on June 
11, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $30 
copayment for Medicare-covered non-radiological diagnostic services.  
 
Review of the file shows that you were provided diagnostic testing services on June 11, 2020. You have been 
asked to pay a $30 copayment for the testing. The testing falls within the outpatient diagnostic 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 testing you received on June 11, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for altered mental status and was treated for a COPD exacerbation. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this patient 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 acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve leadless pacemaker (CPT Code 33274). 
 
You asked the Plan to pre-approve the leadless pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says the requesting provider?s office confirmed that the member is currently not 
part of a CMS approved Coverage with Evidence Development (CED) study but will join the study upon the 
placement of the said pacemaker on Monday (December 21, 2020). The Plan states they requested to give 
information or copy of the CED study that the member will be enrolled from the Cardiologist?s office; 
however, you are unable to provide at this time. The Plan states since the member is not enrolled in a CMS 
CED study and the Cardiologist cannot provide the name or title of the CMS CED Study, we recommend this 
appeal to be upheld due to incomplete information provided. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the leadless pacemaker have not been met. Since the member is not 
enrolled in a CMS CED study and the Cardiologist cannot provide the name or title of the CMS CED  Study,  
we recommend this appeal to be upheld due to incomplete information provided. Therefore, we decided that 
the Plan does not have to pre-approve leadless pacemaker (CPT Code 33274).