Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for a colonoscopy provided on December 28, 2018.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening
and you should not be responsible for the charges. The Plan denied your request. The Plan says that you were
charged the correct copayment amount because the provider billed your colonoscopy as a diagnostic.
The Plan must follow Medicare rules. Medicare covers 1 screening colonoscopy every 2 years or 1 barium
enema every 2 years for people with high risk of colon cancer. An individual with a person history of
adenomatous polyps meets the definition of "person with high risk of colon cancer" under Medicare rules.
There is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were
removed during this colonoscopy. The Plan did not submit any medical records from the ordering provider
showing what type of colonoscopy was ordered or the reason it was ordered. The procedure findings submitted
shows no polyps were removed and results were normal.
A person with a personal history of polyps is considered to be at high risk of colon cancer. People at a high risk
of colon cancer are eligible for screening colonoscopies under Medicare rules and these screening
colonoscopies are covered at a greater frequency for those at high risk. No evidence has been submitted to
show that your screening colonoscopy benefit was exhausted on this date of service. Based on the
documentation submitted by the health plan, we find that you received a screening colonoscopy. We further
find that Plan's contract provider incorrectly billed this colonoscopy as a diagnostic colonoscopy.
Medicare rules say that, if a preventive service is covered with $0 cost-sharing under Original Medicare, the
health plan cannot impose cost-sharing for the service when it is provided by in-network providers. The Plan must follow this rule.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Therefore, we decided that the Plan has to waive the copayment for a
colonoscopy provided on December 28, 2018.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography Angiography (CTA) scans provided
on November 6, 2019.
You asked the Plan to pay for CTA scans. You say that you are appealing. The Plan denied your request. The
Plan says the denial of payment for these services is correct, because these tests were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient
information to determine whether payment is due for a claim.
We looked at the file and Medicare rules. No medical records were submitted to the Plan to support coverage
for this claim as billed. The Plan requested these records, but none were provided. Without this information,
you have not furnished sufficient information to determine that payment is due for these services. Based on this
information, we decided that Medicare rules for coverage of CTA scans have not been met. Therefore, we
decided that the Plan does not have to pay for Computed Tomography Angiography (CTA) scans provided on
November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy for tooth 22 (D3310) and
prefabricated post and core for tooth 22 (D2954).
You asked the Plan to pre-approve endodontic therapy for tooth 22 and prefabricated post and core for tooth
22. You say that the requested services are necessary since you are experiencing pain. The Plan denied your
request. The Plan says the services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve
endodontic therapy for tooth 22 (D3310) and prefabricated post and core for tooth 22 (D2954).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of the Vertiflex Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary as the enrollee has been diagnosed with lumbar canal stenosis. The Plan denied your request. The Plan says that based on the review of existing evidence, there are currently no clinical indications for this technology. Therefore, this service is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that this procedure is considered to be experimental/investigational because of a lack of a robust head to head trial versus decompression surgery. There is also a significant risk of re-operation. Therefore, the request is deemed not medically reasonable or 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of the Vertiflex Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a sclerosant injection (36470).
You asked the Plan to pre-approve a sclerosant injection. You say that the service is necessary. The Plan denied
your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the number of medically necessary sclerotherapy
injection sessions varies with the number of anatomical areas that have to be injected, as well as the response to
each injection.
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 sclerosant injection. Our reviewer
says that the service is medically necessary. Our physician reviewer found the enrollee has had 2 prior
sclerotherapy sessions for her right leg venous insufficiency on March 9, 2020 and April 20, 2020. A duplex
ultrasound on May 4, 2020 demonstrates clinically significant residual disease. The enrollee meets the
coverage criteria. The service at issue in this case is medically reasonable and 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 a sclerosant injection have been met. Therefore, we decided that the Plan has to
pre-approve a sclerosant injection (36470).
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: 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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee's
chronic medical conditions are stable. The enrollee may benefit from additional multiple therapies, however the
enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive
level program.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on December 4, 2019.
You asked the Plan to pay for the crown. You say that you were not aware that you needed prior authorization
for this service. You also say that you feel you should be reimbursed because you were not able to make an
informed decision. The Plan denied your request. The Plan says this service is not covered under your medical
benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the crown provided on December
4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient clinic visit and the laboratory
work provided on October 30, 2019 and November 12, 2019.
You asked the Plan to waive the deductible for the outpatient clinic visit and the laboratory work. You say that
these services were preventive and there is no cost for preventive care. 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. Your
contract with the Plan says that there is a combined in-network and out-of-network $300 deductible that applies
towards in-network outpatient clinic visits and in-network laboratory work.
The outpatient clinic visit you asked the Plan to waive the deductible for falls within the "Outpatient hospital
services, non-surgical" benefit category. The laboratory work you asked the Plan to waive the deductible for
falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan
has followed Medicare rules by clearly disclosing in the contract that there is a combined in-network and outof-
network $300 deductible that applies towards in-network outpatient clinic visits and in-network laboratory
services. This cost sharing is a contractual obligation that had not been met at the time the outpatient clinic visit and the
laboratory work were received on October 30, 2019 to November 12, 2019. Therefore, we decided that the Plan
does not have to waive the deductible for the outpatient clinic visit and the laboratory work provided on
October 30, 2019 and November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a leadless pacemaker provided on October
31, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records
do not indicate the enrollee is part of a CMS approved CED study.
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when
procedures are performed in FDA approved studies.
In this case, the CPT Code Manual definition of code 33274 is transcatheter insertion or replacement of
permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous
ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming),
when performed.
We find that CPT code 33274 was billed with a QO modifier, which indicates an investigational clinical
service provided in clinical research study that is in an approved clinical research study. The records provided
do not indicate that at the time of service, the enrollee was in an approved study. Based on this information, we
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have
to pay for the insertion of a leadless pacemaker provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on February 5, 2020.
You asked the Plan to pay for the dental service. You say that your tooth has been hurting you for several
months. You say that the filling fell out quite some time ago. You also say that your dentist advised that the
tooth should be removed as soon as possible. The Plan denied your request. The Plan says extractions are not
listed as a covered service.
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 extraction is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction (D7140)
provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays, periodic oral evaluation, and
prophylaxis provided on January 7, 2020 by an OON provider.
You asked the Plan to pay for the bitewing x-rays, periodic oral evaluation, and prophylaxis. You say that you
have been going to this same dental location since 2018. You also say that you were not advised that this
location was OON. The Plan denied your request. The Plan says the treating provider is OON. The Plan also
says that services performed by an out-of-network provider are not covered because your healthcare plan does
not have out-of-network 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
covered when they are received OON. The Plan says that the contact history was reviewed and there is no
record of a provider verification call from you prior to the services being rendered. Therefore, we decided that
the Plan does not have to pay for the bitewing x-rays, periodic oral evaluation, and prophylaxis provided on
January 7, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on December 10,
2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this should be covered because the
facility is in-network. The Plan denied your request. The Plan says this service was not authorized.
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 nursing facility care (99309) provided on
December 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 17, 2020 to
January 24, 2020 that were not related to manual manipulation of the spine.
You asked the Plan to pay for these chiropractic services. You say that these services should be covered by the
Plan. The Plan denied your request. The Plan says the services provided were not related to manual
manipulation of the spine.
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 were not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic
services provided from January 17, 2020 to January 24, 2020 that were not related to manual manipulation of
the spine.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on August 8, 2019.
You asked the Plan to pay for the echocardiography. You say that these services were not related to hospice. 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 enrollee's 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 echocardiography provided on August 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 16, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided on December 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous inpatient mental health treatment.
You asked the Plan to pre-approve continuous inpatient mental health treatment. You say that the services are
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria
has not been met.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the enrollee's medical records 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 continuous inpatient mental health treatment have not been met. Specifically, medical records were
not provided. Without this documentation, medical necessity is not able to be established. Therefore, we
decided that the Plan does not have to pre-approve continuous inpatient mental health treatment.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you are
medically stable with no clinical evidence of any unstable medical conditions.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve outpatient therapy visits twice weekly.

You asked the Plan to pre-approve the outpatient therapy visits. You say that the continued services are medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 outpatient therapy visits. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has constitutional symptoms including weight issues, insomnia, agitation, guilt and recurrent thoughts of death. It is not unreasonable to continue therapy at current regimen of twice-weekly with recurrent evaluation for necessity. At this present time this patient does meet criteria for medical necessity for continued twice-weekly treatment.

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 outpatient therapy visits have been met. Therefore, we decided that the Plan has to pre-approve outpatient therapy visits twice weekly. 

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.