Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for diabetic medical supplies provided by a participating 
provider on March 23, 2020. 
 
You asked the Plan to waive the coinsurance for diabetic medical supplies. You say that this should be covered 
100% The Plan denied your request. The Plan says that the correct coinsurance 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 100% covered for diabetic services and supplies.  
 
The Plan says you must pay a 20% coinsurance for diabetic medical supplies. Based on the Plan contract, 
however, you cannot be asked to pay for diabetic medical supplies. Therefore, we decided that the Plan has to 
waive the coinsurance for diabetic medical supplies provided by a participating provider on March 23, 2020.  
 
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 the collection of venous blood by venipuncture or urine 
sample, basic metabolic panel, hemoglobin A1C, and CBC provided on January 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that the enrollee was not under hospice during 
this visit. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the enrollees terminal condition. 
 
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 the collection of venous blood by venipuncture or urine 
sample, basic metabolic panel, hemoglobin A1C, and CBC provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on February 3, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
 Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 3, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
September 9, 2019. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says there is no valid order for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider.  
 
Though there is an order in the file, it is unsigned. There is no medical record supporting the intent for this 
testing. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing 
provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 14, 2020. 
 
You asked the Plan to pay for the services. 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 provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and other drugs and/or 
medicaments (D9630) provided February 18, 2020. 
 
You asked the Plan to pay for the dental services. You say that you have been going to this provider for several 
years and you had called both the plan and the provider prior to scheduling the appointment to make sure you 
were covered. The Plan denied your request. The Plan says these services are not covered under the plan 
benefits. 
 
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 pay for gingival 
irrigation (D4921) and other drugs and/or medicaments (D9630) provided February 18, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on May 
8, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have 
been 2 claims submitted for a 45-minute time frame between 2 emergency room visits. 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 $90 
copayment per visit for emergency care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the ?Emergency care? benefit category. The record shows you had two separate emergency room visits. 
 
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 emergency room visit provided on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased November 18, 2019.
You asked the Plan to pay for the hearing aids. You say that your actual costs are not reflected correctly on the
contract. The cost of the hearing aids was not $1,636 but rather $3,316. $1636 was the cost after subtracting the
trade in discount. The Plan denied your request. The Plan says based on the current claim on file, this claim
was processed and paid 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 $50 copayment for routine hearing exam and there is a $3,000 maximum benefit coverage every 36
months for hearing aids.
The enrollee has been asked to pay $2,358. The claim submitted showed $818 per hearing aid totaling $1,636.
The plan paid $1,636. The plan can only calculate claim totals by what is submitted. The plan does not
reimburse discounted amounts. The hearing aids falls within the Hearing services 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 pay for the hearing aids purchased November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on September 25, 2019. 
 
You asked the Plan to pay for the definitive drug testing. You say that this is medically necessary and should be 
paid. The Plan denied your request. The Plan says the order for this testing is not valid. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing must be ordered by a treating 
provider. While it need not be signed, medical records must support that the testing is intended. 
 
The lab order provided is unsigned and no records are provided to demonstrate the intent to perform this 
testing. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on 
September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient office visit for the evaluation and management of 
a new patient (99203) refraction services (92015) provided April 27, 2020. 
 
You asked the Plan to pay for the vision services. You say that you should not be responsible for the full 
balance of the claim because you were not informed until after you received the services when the provider told 
you you'd have to submit the claim yourself. The Plan denied your request. The Plan says except for emergency 
care, the plan cannot pay a provider who is not eligible to participate in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
outpatient office visit for the evaluation and management of a new patient (99203) refraction services (92015) 
provided April 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vumerity. 
 
You asked the Plan to pre-approve Vumerity. You say that Vumerity is the best choice for the enrollee. The 
Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription 
drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vumerity.  
 
Benefits for Vumerity 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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan. Our reviewer says that the 
requested CT scan is medically reasonable and necessary. Our physician reviewer found the enrollee has 
multiple pain complaints including chest wall pain. The enrollee's pain medications include Lyrica, 
Gabapentin, Celebrex and Suboxone. The enrollee had physical therapy ordered but there is no documentation 
that it has begun. The enrollee's chest x-ray shows a subcortical rib fracture. The physician is working up the 
origin of the enrollee's chest wall pain to rule out facet joint mediated pain. The request is medically reasonable 
and necessary and the enrollee meets the criteria for the requested CT scan. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total hip arthroplasty to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
total hip arthroplasty to be provided by an out of network (OON) provider.
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 enrollee cannot be adequately care for in her current condition at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee's complex medical needs are being met in the current acute setting at this time.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) following multiple surgeries for ischemic bowel. The enrollee was intubated/ventilated perioperatively, but is no longer intubated/ventilated. The enrollee is being allowed to eat, is receiving wound care, and is participating in rehabilitative services. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve a therapeutic CGM.. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a therapeutic CGM is covered when the above criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a therapeutic CGM.. Our reviewer says that the requested therapeutic CGM is not medically reasonable and necessary. Our physician reviewer found that the enrollee uses one injection of basal insulin daily for management of diabetes. There is no documentation that blood sugar is monitored four or more times daily. The enrollee does not meet the above LCD criteria for coverage of the requested therapeutic CGM. 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 therapeutic CGM. have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient mental health care, for the enrollee. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient mental health care. Our 
physician reviewer found it does not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care as the patient did not have 
dangerousness to self or others, perceptual disturbance including auditory or visual hallucinations however the 
patient did have grandiose delusions and religious preoccupation while being cooperative. The health plan's 
denial of inpatient psychiatric services appears appropriate. This patient did not appear to require inpatient 
mental health treatment as the patient was not a danger to themselves or others and was cooperative and 
compliant. It did not appear that active treatment was taking place. It did not appear that the services were 
reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our doctor is unable to 
find an individualized treatment plan however the entire record is not present. It did appear that the records 
were supervised and evaluated by a physician. Based upon review the records provided, for the admission of 
this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown 
to be a danger to themselves or others but was without agitation or aggression without perceptual disturbance 
including auditory, visual hallucinations however the patient did have grandiose delusions but was cooperative 
with no assistance needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says drug coverage is 
limited to Medicare Part B covered drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the chest. 
 
You asked the Plan to pre-approve chest MRI. You say that it was hard to tell on the computed tomography 
(CT) scan whether the enrollee's lung mass was pleural or extrapleural, so you recommend this MRI which will 
help differentiate. The Plan denied your request. The Plan says that the denial of authorization for this service 
is correct, because the enrollee already had a same or similar test done. 
 
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 chest MRI. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found the enrollee has a 
lung mass which is in an area of the lung that is difficult to access for needle biopsy. It is unclear from the chest 
computed tomography whether the mass is intra-pulmonary or extra-pleural. MRI with contrast could assist 
with characterization of the lesion, nearby vascularity, and best approach for biopsy. Therefore, this MRI is 
considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chest MRI have been met. Therefore, we decided that the Plan has to pre-
approve Magnetic Resonance Imaging (MRI) of the chest.  
 
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.