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

 
We decided that the Plan does not have to waive the copayments for bronchoscopies and does not have to 
waive the coinsurance for radiation therapy and a Medicare Part B drug provided from March 19, 2020, to June 
19, 2020. 
 
You asked the Plan to waive the copayments for bronchoscopies and to waive the coinsurance for radiation 
therapy and a Medicare Part B drug. You say that you disagree with the charges. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charge 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 $450 
copayment for outpatient surgery, including services provided hospital outpatient facilities and ambulatory 
surgical centers. Your contract with the Plan also clearly says that you must pay 20% coinsurance for 
therapeutic radiology and Medicare Part B drugs.  
 
 
 
 
You received a bronchoscopy on March 19, 2020. A bronchoscopy is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $450 copayment.  
 
You received a bronchoscopy on March 30, 2020. A bronchoscopy is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the allowed amount of $439.36, which is less than the $450 
copayment. 
 
You received radiation therapy from April 3, 2020, to June 1, 2020. Therefore, you are responsible to pay the 
total amount of $1,599.88, which is less than the 20% coinsurance amount.  
 
You received a bronchoscopy on June 19, 2020. A bronchoscopy is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $450 copayment. You also received a Medicare Part B 
drug. The allowed amount is $6.56 and 20% of that is $1.31. The total amount you owe is: $451.31.  
 
The total amount you owe is: $2,940.55. 
 
You have been asked to pay the total coinsurance amount of $2,940.55 for bronchoscopies, radiation therapy 
and a Medicare Part B drug. Bronchoscopies fall within the outpatient surgery, including services provided 
hospital outpatient facilities and ambulatory surgical centers benefit category. Radiation therapy falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments 
for bronchoscopies and does not have to waive the coinsurance for radiation therapy and a Medicare Part B 
drug provided from March 19, 2020, to June 19, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a Space OAR (55874, A4649). 
 
You asked the Plan to pre-approve a Space OAR. You say that this would benefit the enrollee. The Plan denied 
your request. The Plan says that the member is in an unfavorable intermediate risk group. 
 
The Plan follows Medicare rules. Medicare rules say that Polyethylene-glycol (PEG) hydrogel is covered once 
in patients with clinically localized prostate cancer with the above 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 Space OAR. Our reviewer says that 
this is medically reasonable and necessary in this case. Our physician reviewer found SpaceOAR Hydrogel was 
FDA-cleared in April 2015 and is intended to temporarily position the anterior rectal wall away from the 
 
 
prostate during radiotherapy for prostate cancer. In creating this space, it is the intent of SpaceOAR Hydrogel 
to reduce the radiation dose delivered to the anterior rectum. A recent meta-analysis showed significantly fewer 
rectal toxic effects and higher bowel-related quality of life in late follow-up. This patient has rheumatoid 
arthritis which increases his risk of adverse effects from radiation. 
 
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 Space OAR have been met. Therefore, we decided that the Plan has to pre-
approve a Space OAR (55874, A4649).  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no diagnosis of bronchiectasis. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found there is no 
evidence of a covered diagnosis, such as bronchiectasis, cystic fibrosis, or generalized neuromuscular disease. 
There is insufficient evidence that HFCWO is beneficial in the treatment of chronic bronchitis.  HFCWO is not 
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 a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on March 3, 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 procedure code 19366 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 19366 is breast reconstruction with other technique. 
 
We find that CPT code 19366 is not supported in the medical record. Specifically, there is no documentation of 
a breast reconstruction with other technique. 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 
surgical services rendered on March 3, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cystourethroscopy, with fulguration and/or resection (52240) 
provided March 26, 2020. 
 
You asked the Plan to pay for the surgical services. You say that the medical The Plan denied your request. The 
Plan says the medical records provided support the necessity of the services in dispute. 
 
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 55240 is cystourethroscopy, with fulguration (including 
cryosurgery or laser surgery) and/or resection of LARGE bladder tumor(s). 
 
 
 
We find that CPT code 55240 is not supported in the medical record. Specifically, the submitted medical 
records do not include documentation to support that cystourethroscopy, with fulguration and/or resection of 
large bladder tumor was performed. The plan had made multiple attempts to obtain the additional information 
from the provider without success. Based on this information, we decided that Medicare rules for coverage of 
the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for 
cystourethroscopy, with fulguration and/or resection (52240) provided March 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional two removals of residual tooth roots provided 
on January 23, 2020. 
 
You asked the Plan to pay for the additional removals of residual tooth roots. You say that you were never 
notified that the treating provider was out-of-network. The Plan denied your request. The Plan says payment 
has already been authorized for three of the extraction procedures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to three 
procedures per calendar year. The record shows that you received two surgical extractions and three removals 
of residual tooth roots on January 23, 2020, the extractions and one removal of residual tooth roots were 
covered, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to 
pay for the additional two removals of residual tooth roots provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care services provided on February 15, 2019. 
 
You asked the Plan to pay for the urgent care services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the claim was not received within the 365 day timely filing period. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the urgent care services was not filed until August 21, 2020. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for urgent care services provided on February 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a myocardial perfusion imaging, tomographic (SPECT). 
 
You asked the Plan to pre-approve a SPECT (78452). You say that the enrollee needs a SPECT. The Plan 
denied your request. The Plan says the clinical information does not meet criteria for a SPECT. 
 
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 SPECT. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has atrial flutter but no symptoms or electrocardiographic changes suggestive of coronary 
ischemia. In this circumstance the documentation does not support the medical necessity for nuclear stress 
testing. Isolated atrial dysrhythmias are not considered an appropriate indication for nuclear stress testing. 
Coverage criteria are not met since there are no documented covered indications for the procedure. 
 
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 SPECT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a myocardial perfusion imaging, tomographic (SPECT).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on February 19, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says the anesthesia documentation does not indicate the type of anesthesia or 
start and stop time. 
 
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 01402 is Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty.  
 
We find that CPT code 01402 is not supported in the medical record. Specifically, there is no anesthesia report. 
Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not 
been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on 
February 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because the 
stains were necessary due to clinical concerns and the possibility of fungal infection. The Plan denied your 
request. The Plan says non-urgent services should be from network providers who are contracted with the 
member's healthplan. 
 
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 July 23, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on January 20, 
2020. 
 
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration based 
on the records submitted. 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 member'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 subsequent hospital care (99232) provided on January 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Group 3 power wheelchair repairs. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do 
not have a diagnosis for which a Group 3 power wheelchair is reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
certain medical 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 the requested services. Our physician 
reviewer found that you have a history of morbid obesity, atrial fibrillation, hypertension, end-stage renal 
disease, sleep apnea, hypothyroid, anemia, CAD, dyslipidemia, asthma, and congestive heart failure. A Group 
3 wheelchair is covered when there is a mobility limitation due to a neurological condition, myopathy, or 
congenital skeletal deformity. The documentation does not indicate a diagnosis of a neurological condition. 
There is no documentation of a myopathy or congenital skeletal deformation in the submitted medical progress 
reports. Therefore, the requested services are 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Group 3 power wheelchair repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immunization provided on July 21, 2020. 
 
You asked the Plan to pay for the Zoster preventative immunization (90471, 90750). You say that this 
procedure was performed out of necessity. The Plan denied your request. The Plan says the Zoster 
immunization is not covered as a preventative service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster 
preventative immunization (90471, 90750). The Plan follows the same rules.  
 
Records do not show that the enrollee has not been injured or directly exposed to any illness related to the 
Zoster preventative immunization (90471, 90750). Therefore, we decided that the Plan does not have to pay for 
the immunization provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for a knee ankle foot device. 
 
You asked the Plan to pre-approve for the knee ankle foot device. You say that you are in need of a new brace 
and you are asking for the new C-Brace which gives movement in your ankle. You say that you are in 
desperate need of this movement because of circulation issues with an ulcer. You say that the out of network 
DME provider will do all of the measurements and adjustments, but that your primary care physician refuses to 
write a prescription for the brace. The Plan denied your request. The Plan says the appeal information indicates 
that your doctor would not write an order for this brace and you are requesting this brace from an out of 
network provider without your physician's support. The Plan says that multiple attempts were made to contact 
your physician regarding your request without success. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a physician 
order. 
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the item requested in this case.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pre-approve 
for a knee ankle foot device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for this enrollee. The Plan denied your request. The Plan says there is no clinical advantage of LTACH over 
acute hospital 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the health plan?s denial of LTACH coverage should be upheld. There is no evidence 
that the enrollee requires services that are not currently available.  As LTACHs and acute care hospitals (ACH) 
are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
The enrollee can remain at the current ACH until such time no acute services are required.  The enrollee can 
then be transferred/discharged to a lower level of care for any ongoing long term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from 
June 21, 2020, to June 30, 2020. 
 
You asked the Plan to pay for the SNF services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says they have already approved 100 days of 
SNF care. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from December 20, 2019, to 
June 20, 2020. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing facility (SNF) services provided from June 21, 2020, to June 
30, 2020.