Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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. 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 you were able to walk 30 feet with a rolling walker. The documentation does not 
support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The documentation does not support that you require an intensive therapy program with therapy 3 hours 
per day, with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 20, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab test. You say that the enrollee does not go to your lab as the treating doctor 
sends you the specimen to process. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-
of-network with the Plan. 
 
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 May 20, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cataract surgery you had at an 
outpatient hospital facility on May 26, 2020. 
 
You asked the Plan to waive the copayment for the cataract surgery at an outpatient hospital facility. You say 
that if you had known this copayment would be this high, you would have stayed with your other insurance. 
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 $250 
copayment for surgery at an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for the cataract surgery at an outpatient hospital facility. 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 cataract surgery you had at an outpatient hospital facility 
on May 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (H2035) provided from March 2020, to March 
31, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee 
Schedule indicates that the code in question is not valid for Medicare purposes.  
 
We looked at the file and Medicare rules. Code H2035 is assigned a status indicator of ?I? under the Physician 
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for 
reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services (H2035) provided from March 2020, to March 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 71046) provided to the enrollee. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appropriate modifier was not appended in this case. 
 
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 71046 is "radiologic examination, chest." 
 
We find that CPT code 71046 is not supported in the medical record. Specifically, a modifier showing that this 
was a distinct service was not appended to the code on the claim. 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 radiology services (CPT 71046) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from November 19, 2019, to December 
23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says additional payment 
cannot be made. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has determined 
that the primary insurer has paid up to the limits of its coverage and the charges that remain are deductibles and 
coinsurance charges. Therefore, we decided that the Plan does not have to pay for the services provided from 
November 19, 2019, to December 23, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two ultrasounds of leg arteries (93925 and 
93922) performed on January 30, 2020. 
 
You asked the Plan to waive the copayment for two ultrasounds of leg arteries. You say that these were not 
major ultrasound tests. 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 $160 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $160 copayment and a $61.70 copayment for two ultrasounds of leg arteries. 
Ultrasounds of leg arteries 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 or less than the full 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 two 
ultrasounds of leg arteries (93925 and 93922) performed on January 30, 2020.
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 the seat lift mechanism. You say that you would like reconsideration 
because this supply is medically necessary. The Plan denied your request. The Plan says there is no 
documentation that you are able to walk once in a standing position or that the device will help slow the decline 
of your condition. 
 
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 seat lift mechanism. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that a seat lift is likely to affect improvement in 
your condition or arrest deterioration in your condition. The records do not indicate that the you are completely 
incapable of standing from a chair in the home on a physical exam. The records do not clearly indicate that you 
can ambulate. 
 
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 seat lift mechanism have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established patient office or other outpatient (99214) 
provided on November 27, 2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for the established patient office or other outpatient. You say that the provider 
should not be out of network with the Health Plan. The Plan denied your request. The Plan says prior 
authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied 
 
 
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 established patient office or other outpatient 
(99214) provided on November 27, 2019, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional speech therapy visits in the home setting. 
 
You asked the Plan to pre-approve additional speech therapy. 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. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional speech therapy. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found you have had prior therapy for this condition and it does not 
appear that you require the unique skills of a professional therapist to safely and effectively provide treatment, 
that the services can be safely and effectively performed only by a therapist, or under the supervision of a 
therapist.  
 
 
You have been authorized additional sessions to review an independent exercise program. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain your current condition or to prevent or slow further deterioration. 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 additional speech therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 8 additional speech therapy visits in the home setting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from 
April 8, 2020 to April 16, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
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 $350 
copayment each day, for days 1 to 5 and a $0 copayment each day, for days 6 to 90 for in-network Medicare-
covered hospital care.  
 
You have been asked to pay $1,750 ($350 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from April 8, 2020 to 
April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) on June 16, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you were informed by the 
provider that you would have no copayment. The Plan denied your request. The Plan says the correct 
copayment 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 $45 
copayment for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $45 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 (99214) on June 16, 2020.  
 
Your complaint about receiving erroneous or misleading information from the provider is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit you had on 
June 30, 2020. 
 
You asked the Plan to waive the copayment for the primary care office visit. You say that you received a 
postcard from your plan stating that office visit copays would be waived starting July 1, 2020.  You said that 
you did not receive this postcard until July 6, 2020.  You say that if you had known that copayments would be 
waived, you would have rescheduled your visit. The Plan denied your request. The Plan says you were charged 
this copayment correctly.  You received these services prior to the copayment waiver going into effect. 
 
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 $25 
primary care visits.  This copayment applies for all primary care visits received prior to July 1, 2020.  
 
You have been asked to pay a $25 copayment for the primary care office visit. These services were rendered 
before the copayment waiver went into effect. 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. There is no provision in the copayment waiver documentation that says that copayments 
for services rendered prior to the waiver will also have copayments waived. Therefore, we decided that the Plan 
does not have to waive the copayment for the primary care office visit you had on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 23, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 lab services provided on November 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs system for the enrollee. 
 
You asked the Plan to pre-approve a CardioMEMs system. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this is considered investigational or experimental. 
 
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 a CardioMEMs system. Our reviewer 
says that a CardioMEMs system is not considered medically reasonable and necessary in this case. In this 
circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in 
only one 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. Our physician reviewer found that the enrollee's condition does not 
meet criteria for coverage of a CardioMEMs system. 
 
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 CardioMEMs system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs system for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve whole breast radiation therapy in 26 fractions using 3D 
conformal radiation, as well as a boost of 7 fractions of photon therapy. 
 
You asked the Plan to pre-approve the radiation therapy at the number of fractions requested. You say that it is 
felt that the radiation therapy is necessary as ordered. The Plan denied your request. The Plan says the widely 
accepted number of fractions of radiation treatment have been approved. Fractions in excess of this amount are 
not shown to be 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 the radiation therapy at the number of 
fractions requested. Our reviewer says that the requested number of fractions of radiation therapy is not 
considered medically reasonable and necessary in this case. Our physician reviewer found the most recent 
NCCN guidelines state that for whole breast radiation, hypofractionation is preferred (based on data from 4 
randomized studies) though state that doses of 45-50.4 in 25-28 fractions could be considered. The 2018 
ASTRO Executive summary of evidence-based guideline for breast cancer (Smith et al) states: ?For women 
with invasive breast cancer receiving WBI with or without inclusion of the low axilla, the preferred dose-
fractionation scheme is hypofractionated WBI to a dose of 4000 cGy in 15 fractions or 4250 cGy in 16 
fractions? There was 100% consensus on this statement, with a high grading of the evidence and strong 
recommendation. The committee thought that rare histologies (i.e. small cell, sarcoma, melanoma, etc) could 
 be considered for conventional fractionation (i.e. more fractions). Age, margin status, tumor grade, cancer 
laterality, prior chemotherapy, hormone or Her2 receptor status, or breast size were not thought to be important 
criteria to favor conventional fractionation.  
 
As hypofractionation is considered the standard approach, and with no justification of more conventional 
fractionation in this patient, it is found that additional fractions would not be in accordance with accepted 
standards of medical practice. There is likewise no argument provided for 7 boost fractions rather than the 
standard 5.  
 
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 radiation therapy at the number of fractions requested have not been met. 
Therefore, we decided that the Plan does not have to pre-approve whole breast radiation therapy in 26 fractions 
using 3D conformal radiation, as well as a boost of 7 fractions of photon therapy.