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

We decided that the Plan does not have to waive the copayment forphysician services provided on February 28, 2020.You asked the Plan to waive the copayment forthe physician services. You say that you are being billed by the physician and did not have a urinalysis on this date of service.The Plan denied your request. The Plan says you were charged the copayment correctly and the physician discussed results of a urinalysis from a previous teston February 26, 2020.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 $50 copayment for Specialist Visit. You have been asked to pay a $50 copayment for the physician services. The physician services fall within the Specialist Visit 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 Plan has confirmed with the provider that you are not being charged for a urinalysis and the $46.29 is a previous balance. Therefore, we decided that the Plan does not have to waive the copayment forphysician services provided on February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure (CPT Codes: C2624 and 
33289). 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says a review of the current medical literature indicates that this service is 
considered experimental and investigational. 
 
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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance, therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met, since the device should still be considered experimental or 
investigational. 
 
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 CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure (CPT Codes: C2624 and 33289).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services (S9122) provided June 1, 2020.You asked the Plan to pay forthe home health services. You say that the services were medically necessary.The Plan denied your request. The Plan says this service is not eligible for Medicare payment.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 S9122 is not supported in the medical record. Specifically, CPT code S9122 is marked with a status of "I" per the 2020 National Physician Fee Schedule. This code is invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met.Therefore, we decided that the Plan does not have to pay forhome health services (S9122) provided June 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation stay provided on January 16, 2020.You asked the Plan to waive the copayment forthe observation stay. You say that you should not have a to almost $300 for an emergency room visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 copayment per visit for Medicare-covered outpatient observation services. You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the "Outpatient hospital observation" benefit category. The record shows you were admitted for observation and your emergency room copayment was waived.
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 forthe observation stay provided on January16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would greatly benefit from care that can be provided at the LTACH level of care.The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.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 does not require services at the LTACH that are not already available at the current facility. Our reviewer found that there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Our physician reviewer also found that transfer may be considered when treatment has been effectively completed.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-approveLTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pontic (D6245) and retainer crowns (D6740) for teeth #'s 18 and 20.You asked the Plan to pre-approvethe pontic and retainer crowns. You say that you need this bridge.The Plandenied your request. The Plan says pontics are not covered. The Plan also says that tooth #'s 18 and 20 are posterior teeth, and the Plan only covers retainer crowns for anterior teeth.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, pontics (D6245) are not among those covered under this benefit. The contract also clearly states that fixed bridges are to replace one missing anterior tooth per arch, and teeth #'s 18 and 20 are posterior teeth.Therefore, we decided that the Plan does not have to pre-approvea pontic (D6245) and retainer crowns (D6740) for teeth #'s 18 and 20.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc.You asked the Plan to pre-approveSynvisc. You say that you have brain aneurisms and physical therapy has caused more pain your knees. You say that you need this injection.The Plan denied your request. The Plan says the criteria for coverage is not met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Synvisc. Our reviewer says that Synvisc is not medically reasonable or necessary. Our physician reviewer found no documentation of intolerance of topical NSAID or history of failure for at least threemonths. Our physician reviewer found no documentation that you had an inadequate response to a minimum of threemonths of physical therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2020. 
 
You asked the Plan to pay for the services provided. You say that the services are separate and distinct 
procedures. The Plan denied your request. The Plan says a valid modifier was not billed on the claim. 
 
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 93923 is complete bilateral noninvasive physiologic 
studies of upper or lower extremity arteries. The rules say that the service may be billed with procedure code 
93924 with an appropriate modifier. We find that CPT code 93923 was not billed with a modifier to indicate 
the services are separately payable. 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 medical services provided 
on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99214) provided March 4, 2019. 
 
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this claim has already been paid. 
 
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 99214 is not supported in the medical record. Specifically, records only support 1 unit 
of CPT code 99214 being billed. This service was already paid for the date of service at issue. Based on this 
information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we 
decided that the Plan does not have to pay for an office visit (99214) provided March 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 86769) provided on July 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit of this 
code is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 2 units of CPT code 86769 are not supported in the medical record. The medical record only 
supports 1 unit of CPT code 86769, which the Plan previously processed and paid. 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 services (CPT 86769) provided on July 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says care can be provided in the current inpatient hospital. 
 
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 there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a problem focused limited oral evaluation.
You asked the Plan to pre-approve the problem focused limited oral evaluation. You say that you would like the home dental evaluation of a tooth, or transport by stretcher for a dental evaluation to be reconsidered. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not covered.
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 a problem focused limited oral evaluation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not at her baseline, and
needs daily skilled nursing care and therapy services in a nursing home to get back to her baseline and be able
to return home. The Plan denied your request. The Plan says the requested services are considered custodial
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 admission. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. 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. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to preapprove
the SNF admission.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on June 25, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says 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 says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
psychotherapy 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 psychotherapy services provided on June 25, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the vision services provided on September 
28, 2020. 
 
You asked the Plan to reduce the cost share for the services provided. You say that you expected a $15 copay. 
The Plan denied your request. The Plan says the copay was applied per the benefit language. 
 
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 
copay for services to diagnose and/or treat a disease or condition of the eye.  
 
The medical records provided show that you were seen for a complete eye exam, and a diabetic exam. 
However, the provider in this case is not a network provider with the Plan. You have been asked to pay a $45 
copay for the services. The services fall within the vision 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 reduce the cost share for the vision services provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient services provided on September 11, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that these services were medically necessary. You 
say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior 
authorization was not obtained. The Plan says that these services could have been provided in-network. 
 
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 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 outpatient services provided on September 11, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the practitioner services provided on July 14, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the practitioner services. You say that your provider provided medically 
necessary services in good faith. The Plan denied your request. The Plan says prior authorization was not 
requested. 
 
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 had network providers 
available who could have provided 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 practitioner services provided on July 14, 2020 by an out of network 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME provided on October 1, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges because you 
do not remember receiving the device. 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 20% 
coinsurance for DME and related supplies.  
 
The record shows that you received DME on October 1, 2020. The allowed amount is $48.94 and 20% of that 
is $9.79.  
 
You have been asked to pay the total coinsurance amount of $48.94 for DME. DME falls within the DME and 
related 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 coinsurance for DME provided on 
October 1, 2020.