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

 
We decided that the Plan does not have to waive the copay for the lab services provided on May 28, 2020. 
 
You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says 
the copay was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copay per day, per provider, for Medicare-covered lab services.  
 
You have been asked to pay a $20 for the lab services. The services fall within the outpatient diagnostic tests 
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 copay for the lab services provided on May 28, 
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 the services are medically necessary. 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 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 are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to a lower level of care may be considered when the 
enrollee is more stable and weaning has been safely 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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urology services (99213, 51741, 51798) provided on June 
19, 2020. 
 
You asked the Plan to pay for the urology services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the services were not emergent or pre-authorized and 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 urology services (99213, 51741, 51798) provided on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge services rendered on January 15, 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 services are not covered. 
 
The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is 
payable per patient per hospital stay. 
 
We looked at the file and Medicare rules. The Plan previously paid hospital discharge services for this enrollee 
for the hospital stay at issue. 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 hospital discharge 
services rendered on January 15, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy and biopsy provided by a participating 
provider on August 3, 2019. 
 
You asked the Plan to waive the copayment for a colonoscopy and biopsy. You say that you shouldn't have a 
copayment for this. The Plan denied your request. The Plan says that the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for outpatient surgery.  
 
The Plan says you must pay a $50 copayment for a colonoscopy and biopsy. Based on the Plan contract, 
however, you cannot be asked to pay more than a $0 copayment for a colonoscopy and biopsy. Therefore, we 
decided that the Plan has to waive the copayment for a colonoscopy and biopsy provided by a participating 
provider on August 3, 2019.  
 
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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee from November 
8, 2019 to November 18, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says this claim should be submitted to Original Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit 
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for 
physician services provided to the enrollee from November 8, 2019 to November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve humidifier, heated, used with positive airway pressure 
device (CPT Code E0562) and CPAP device (CPT Code E0601). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not 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 DME. Our physician reviewer 
found criteria for continued coverage of CPAP are not met. You have obstructive sleep apnea (OSA).  The 
records do not indicate when CPAP was prescribed, and there are no compliance data. The note indicates you 
are having difficulty using the CPAP because of claustrophobia, but do experience benefit when you use it. 
Continued coverage of CPAP requires evidence of usage for at least four (4) hours/day for at least 70% of days. 
Without that, CPAP is considered not medically necessary, and the denial is upheld. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve humidifier, heated, used with positive airway pressure device (CPT Code E0562) and CPAP 
device (CPT Code E0601).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the services are 
necessary. The Plan denied your request. The Plan says you exhausted your benefit and the services are not 
supported for medical necessity. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 25th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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 documentation does not support that you require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no required medical 
services identified that are available at the LTACH, that are not available at the current health care setting 
being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, 
reasonable, and appropriate for your diagnosis and condition 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the knee (73562) and lab services (84443) 
provided November 14, 2019. 
 
You asked the Plan to pay for the x-ray and lab test. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says rules for coverage were not met for these 
services. 
 
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 73562 & 84443 is x-rays; knee; 3 views. 
 
We find that CPT codes 73562 & 84443 are not supported in the medical record. Specifically, the record does 
not support that 3 views were taken of the knee. Additionally, CPT code 84443 is not covered when performed 
as a screening test. Based on this information, we decided that Medicare rules for coverage of the x-ray and lab 
test have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the knee 
(73562) and lab services (84443) provided November 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided by a participating 
provider on June 23, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you cannot afford this copayment. 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 $325 
copayment for outpatient diagnostic tests/diagnostic radiology services.  
 
You have been asked to pay a $325 copayment for an MRI. The correct copayment has been applied to the 
services that were provided. An MRI falls within the outpatient diagnostic tests/diagnostic radiology 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 an MRI provided by a 
participating provider on June 23, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 2 emergency room visits (99282 and 
99284) on May 13 and May 14, 2020. 
 
You asked the Plan to waive the copayments for 2 emergency room visits. You say that you should not have to 
pay both of these charges. The Plan denied your request. The Plan says the correct copayments were 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 $110 
copayment for each covered emergency room visit.  
 
You have been asked to pay $220, or a $110 copayment for each of 2 emergency room visits. Emergency room 
visits fall within the "Emergency 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 copayments 
for 2 emergency room visits (99282 and 99284) on May 13 and May 14, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the neck and spine. 
 
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is 
medically necessary for a diagnosis. The Plan denied your request. The Plan says that the medical records did 
not provide a thorough examination which indicates cervical radiculopathy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
MRI is medically reasonable and necessary. Our physician reviewer found the radicular nature of the pain 
suggest involvement of the cord.  The MRI is the best mean for diagnosis.  This could result in the need for 
surgery. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
an MRI of the neck and spine.  
 
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 an extraction (D7210) of tooth #4. 
 
You asked the Plan to pre-approve the extraction. You say that you need a denture because you have no teeth. 
The Plan denied your request. The Plan says the benefit for the extraction of tooth #4 has 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to once per 
tooth per lifetime. The record shows that tooth #4 was extracted on July 2, 2020, and your extraction benefit for 
tooth #4 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an extraction 
(D7210) of tooth #4.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 19, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you were receiving care from this provider under 
your previous insurance plan, and this was follow-up care. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because this provider is out-of-network with the Plan, the 
ordering provider is out-of-network with the Plan, and prior authorization was not obtained. 
 
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 June 19, 2020 by 
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of materials for home prothrombin 
time/international normalized ratio (PT/INR) monitoring provided from February 2, 2020, to February 22, 
2020. 
 
You asked the Plan to pay for home PT/INR monitoring. You say that there is no frequency limitation for code 
G0249 except that testing does not occur more frequently than once per week. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because these codes were billed less than 25 
billing days after previously covered billings of G0249. 
 
The Plan must follow Medicare rules. Medicare rules say that the billing frequency for home INR monitoring 
code G0249 is each 25 days.  
 
We looked at the file and Medicare rules. Code G0249 was billed and covered for date of service January 23, 
2020; therefore, the billing of this same code for date of service February 2, 2020 and February 10, 2020 
exceeds the frequency limit. Code G0249 was billed and covered for date of service February 19, 2020; 
therefore, the billing of this same code for date of service February 22, 2020 exceeds the frequency limit. Based 
on this information, we decided that Medicare rules for coverage of home PT/INR monitoring have not been 
met. Therefore, we decided that the Plan does not have to pay for provision of materials for home prothrombin 
time/international normalized ratio (PT/INR) monitoring provided from February 2, 2020, to February 22, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 4, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you believe that this 
copayment qualifies to be waived. The Plan denied your request. The Plan says the copayment you are being 
charged is correct, and that specialist visits are excluded from the waived out-of-pocket costs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for in-network provider and professional services in a specialist's office.  
 
You have been asked to pay a $35 copayment for a specialist office visit. A specialist office 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 office visit provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent 75mg/ml Pen. 
 
You asked the Plan to pre-approve Praluent. You say that Praluent is medically necessary. The Plan denied 
your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
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 Praluent 75mg/ml Pen.  
 
Benefits for Praluent 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy surgery. 
 
You asked the Plan to pre-approve panniculectomy. You say that the enrollee's condition is troublesome, and 
she has tried creams/lotions in the past but has had recurrent rashes and panniculitis. The Plan denied your 
request. The Plan says the denial of authorization for this service is correct, because the documentation does 
not show that the enrollee meets the Medicare criteria for panniculectomy. 
 
The Plan follows Medicare rules. Medicare rules say that panniculectomy is only covered under certain clinical 
conditions. 
 
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 panniculectomy. Our reviewer says that 
the enrollee does not meet the Medicare criteria for the requested panniculectomy. Our physician reviewer 
found the documentation does not support that the enrollee has complicating factors such as inability to walk 
normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, or that the 
symptoms have been present for at least three months and are refractory to usual standard medical 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 panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve panniculectomy surgery.