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

 
We decided that the Plan does not have to pay for the moderate sedation services rendered on October 21, 
2019. 
 
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 G0500 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 G0500 is moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 
years or older (additional time may be reported with 99153, as appropriate). 
 
We find that CPT code G0500 is not supported in the medical record. Specifically, there is no documentation 
of an independent trained observer to assist in monitoring the enrollee's level of consciousness and 
physiological status. 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 moderate sedation services 
rendered on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on December 5, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
services 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 laboratory services provided on December 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services you received on March 6, 2020. 
 
You asked the Plan to pay for the chiropractic services. You say that the services were necessary. The Plan 
denied your request. The Plan says these services are not covered when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services you received on March 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says no documentation was received to support the medical necessity for a step therapy 
exception. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 injection. Our reviewer says that the 
requested injection is not medically necessary and does not meet the step therapy criteria. Our physician 
reviewer found the enrollee is noted to have left knee osteoarthritis. The health plan requires that other forms of 
hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these 
other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other 
forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid 
would not be expected to be safe and effective for the enrollee. Therefore, the requested Synvisc is not shown 
to be currently medically necessary 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that the enrollee has a catastrophic life-threatening 
diagnosis in which the requested therapy is needed. The Plan denied your request. The Plan says IMRT is the 
currently recommended standard. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is an inadequate documentation of the need for this type of therapy. The case file does not provide 
a plausible rationale that would meet the ASTRO criteria by showing a reduction in normal tissue exposure. A 
dosimetic rationale was not provided in this case, in which an insufficient 3D or IMRT plan justified the need 
for 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 the therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided to 
the enrollee from May 31, 2019 to June 11, 2019. 
 
You asked the Plan to waive the copayment for these services. The Plan denied your request. The Plan says that 
the claim processed 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $450 copayment per day, days 1 to 4 of Inpatient hospital care.  
 
The enrollee has been asked to pay a $1,800 copayment for these services. These services fall within the days 1 
to 4 of Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the inpatient hospital services provided to the enrollee from May 31, 2019 to June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance ($13.80) charged for a walker purchased 
on March 13, 2020. 
 
You asked the Plan to waive this coinsurance. You say that you were told the walker was covered 100%. The 
Plan denied your request. The Plan says this coinsurance was applied based on the claim submitted by the 
provider and your Plan contract agreement. 
 
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 durable medical equipment, such as walkers.  
 
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 20% coinsurance ($13.80) charged for a walker purchased on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for blepharoplasty provided on December 2, 
2019. 
 
You asked the Plan to waive the copayment for blepharoplasty. You say that you thought that you would only 
owe a copayment for the surgery. You also state that you were not aware that there was in a difference in 
cost-sharing charges between a hospital facility and an ambulatory surgical center. 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 
copayment for each visit to an outpatient hospital facility.  
 
You have been asked to pay a copayment for blepharoplasty. Blepharoplasty falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for blepharoplasty provided on December 2, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sleep study. 
 
You asked the Plan to pre-approve a sleep study. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sleep studies are only covered for certain indications. 
 
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 sleep study. Our reviewer says that 
the documentation does not support that the requested sleep study is medically reasonable or necessary. Our 
physician reviewer found there is insufficient information in the medical record to determine the need for a 
polysomnography. The documentation indicates that you have "sleep problems" but the nature of the problems 
and symptoms involved are not provided. There is no detailed sleep history. There is no mention of snoring, 
observed apneas, excessive daytime sleepiness, or symptoms of parasomnias. There is no physical examination 
with a detailed exam of the upper airway and no body mass index. Therefore, you do not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a sleep study.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LINX procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation fails to indicate severe or life-threatening GERD that has been 
resistant to medical treatment. 
 
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 procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee's condition does not meet NCD criteria for severe or life threatening 
gastroesophageal reflux disease, nor can her GERD be considered medically-refractory. The complaint of 
dysphagia is a relative contraindication to LINX implantation. Further, the LINX device is not FDA-approved 
for use in the setting of nondysplastic Barrett's esophagus - a condition which of itself may be considered a 
predecessor to esophageal adenocarcinoma but is not imminently life threatening with appropriate surveillance 
and ongoing medical management of GERD. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the LINX procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the bitewing x-rays, four radiographic images (D0274) provided on March 2, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical first radiographic image (D0220) and the bitewing x-rays, four radiographic images (D0274) 
provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for laser eye surgery provided on September 20, 
2019. 
 
You asked the Plan to reimburse you for the laser eye surgery. You say that your doctor recommended laser 
eye surgery to reduce ocular hypertension bilateral. You say that while you were traveling in Columbia you 
developed signs and symptoms of angle closure. The Plan denied your request. The Plan says your primary 
care physician did not provide you with a referral to receive vision services in Columbia. 
 
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 reimburse you 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 
services at issue. We found no exception that would require the Plan to reimburse you for these services. 
Therefore, we decided that the Plan does not have to reimburse you for laser eye surgery provided on 
September 20, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 6, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services 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 subsequent nursing facility care provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 through 
January 23, 2020. 
 
You asked the Plan to pay for the medical services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says there is insufficient documentation how the 
member came to the servicing provider or whether the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the medical services have not been met. Specifically, the record indicates that the Plan requested 
medical records. Without these records we are unable to confirm that Medicare coverage criteria have been 
met. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 
2020 through January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for infusion services (J7050, J1745, 96413) 
provided May 28, 2019 to March 20, 2020. 
 
You asked the Plan to waive the coinsurance for the infusion services. You say that the coinsurance should be 
waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% 
coinsurance for Part B Drugs and a $35 copayment for lab . 
 
You have been asked to pay a 20% coinsurance for Part B Drugs provided during the infusion treatments 
(Remicade) and a $35 copayment for lab services. 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 
infusion services (J7050, J1745, 96413) provided May 28, 2019 to March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99239) 
provided March 10, 2019. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that the provider is not 
contracted with the plan so should not held to timely filing. You ask that this claim be paid to this office 
immediately. The Plan denied your request. The Plan says the provider has billed with incorrect place of 
service. The claim will be reprocessed once a corrected claim is received within timely filling. 
 
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 provider billed this claim incorrectly without a place of service. The plan says that a corrected 
claim must be provided. Based on this information, we decided that Medicare rules for coverage of the hospital 
discharge day management services have not been met. Therefore, we decided that the Plan does not have to 
pay for the hospital discharge day management services (99239) provided March 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation (97014) and therapeutic exercises 
(97110) or waive the copayment for the manual manipulation (98941) provided on February 4, 2020 through 
February 6, 2020. 
 
You asked the Plan to pay for the electric stimulation (97014) and therapeutic exercises (97110) and waive the 
copayment for the manual manipulation. You say that you would like reconsideration because these services 
were necessary and incidental medical treatment. The Plan denied your request. The Plan says electric 
stimulation and therapeutic exercises are not covered under the member's Plan coverage for chiropractic 
services. Additionally, the member's cost share amount has been 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 $16 
copayment for chiropractic services.  
 
You have been asked to pay a $16 copayment for manual manipulation of the spine. The manual manipulation 
of the spine falls within the chiropractic 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.  
 
Additionally, the Plan only covers manual manipulation of the spine. Electric stimulation and therapeutic 
exercises are not covered under the chiropractic services benefit. Therefore, we decided that the Plan does not 
have to pay for the electric stimulation (97014) and therapeutic exercises (97110) and waive the copayment for 
the manual manipulation (98941) provided on February 4, 2020 through February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy services. 
 
You asked the Plan to pre-approve laminectomy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve laminectomy services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you have spinal stenosis. The documentation does not support that there has been an 
adequate trial and failure of conservative measures to include physical therapy for back pain. More 
conservative measures are needed. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of laminectomy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve laminectomy services.