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

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on July 26, 2019. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that your copayment should 
only be $5-$10. You say that you did not spend the night at the hospital. The Plan denied your request. The 
Plan says the correct copayment has been 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 $50 
copayment for colorectal cancer screening/diagnostic colonoscopy.  
 
You have been asked to pay a $50 copayment for a diagnostic colonoscopy. Since a diagnostic colonoscopy 
was provided, the correct copayment has been applied. A diagnostic colonoscopy falls within the colorectal 
cancer screening/diagnostic colonoscopy 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 diagnostic colonoscopy provided by a participating provider on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upgrade from a microprocessor C-leg to a Genium x3 
microprocessor leg prosthesis. 
 
You asked the Plan to pre-approve the upgrade. You say that this is medically necessary. The Plan denied your 
request. The Plan says duplicate or redundant durable medical equipment is not covered. 
 
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 upgrade. Our reviewer says that the 
requested an upgrade from a microprocessor C-leg to a Genium X3 microprocessor leg prosthesis is not 
considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence 
in the documentation that you need this military grade prosthesis that can be used in physically demanding 
occupations, situations with exposure to sand, grime, dirt or Cockpit app to connect with a smartphone. The 
request exceeds the enrollee's medical 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 upgrade have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an upgrade from a microprocessor C-leg to a Genium x3 microprocessor leg prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the services provided from January 31, 
2020 through February 24, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
You received specialist services on January 31, 2020. You are responsible for a $35 copayment for specialist 
services. Furthermore, you received outpatient surgical services on February 24, 2020. You are asked to pay a 
$295 copayment for the services. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the services provided from 
January 31, 2020 through February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14040) provided 
on February 3, 2020. 
 
You asked the Plan to pay for the adjacent tissue transfer or rearrangement. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
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 14040 is  adjacent tissue transfer or rearrangement, 
forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the adjacent tissue transfer or rearrangement. Our reviewer 
says that CPT code 14040 does not meet criteria for billing or reimbursement consideration. Our reviewer 
found the operative report did not include a full description of CPT 14040.  Documentation to verify the size of 
the area is not included, as well as, additional incisions to perform an adjacent tissue transfer, therefore CPT 
14040 cannot be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the adjacent tissue transfer or rearrangement have not been met. Therefore, we 
decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14040) provided on 
February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessories (swingaway, trunk/hip 
support, power attendant control, mount). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says these services are either not covered or already completed/approved. 
 
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 accessories. Our reviewer says that 
the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis 
or treatment of illness or injury or to improve the functioning of a malformed body member. Per documentation 
and the Medicare rules, the swingaway (E1028) and trunk/hip support (E0956) were already approved and a 
duplicate request is not medically necessary. Additionally the attendant control (E2331) is not medically 
necessary as the documentation indicates that you can use the power wheelchair independently to complete 
MRADLs. 
 
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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair accessories (swingaway, trunk/hip support, power attendant control, 
mount).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 45172) provided on October 18, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 45172 is "Excision of rectal tumor, transanal approach; 
including muscularis propria (ie, full thickness)". 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of CPT code 45172 is not supported by the records provided. Our coding reviewer found that the medical 
records provided do not include documentation of an "Excision of rectal tumor, transanal approach; including 
muscularis propria (ie, full thickness)" being performed on October 18, 2019. 
 
We looked at this coder?s review, the file, and Medicare rules. 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 (CPT 45172) provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (A6021) provided on November 21, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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. 
 
We asked our coding 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 pay for the services. Our reviewer says that the use 
of code A6021 is not supported by the records provided. Our coding reviewer found that the documentation did 
not include Proof of Delivery with patient signature. Therefore, the item cannot be verified as delivered to the 
enrollee. 
 
We looked at this coder?s review, the file, and Medicare rules. 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 (A6021) provided on November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for arthroplasty (27447) provided on September 12, 2019. 
 
You asked the Plan to pay for the arthroplasty. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted did not include 
documentation of Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without 
patella resurfacing (total knee arthroplasty). 
 
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 27447 is arthroplasty, knee, condyle and plateau; medial 
AND lateral compartments with or without patella resurfacing (total knee arthroplasty). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the arthroplasty. Our reviewer says that CPT code 27447 
does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did 
not include CPT 27447, therefore, cannot be verified as performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the arthroplasty have not been met. Therefore, we decided that the Plan does not 
have to pay for arthroplasty (27447) provided on September 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the requested physical 
therapy is 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 physical 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 the requested therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition. The enrollee has had 10 sessions of physical therapy and her 
current Oswestry score indicates that she has minimal disability. The records do not indicate recent physical 
exam specific objective deficits that require the unique skills of a professional therapist to safely and 
effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist or 
under the supervision of a therapist. The requested services are not part of a maintenance 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 8 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedures and activities (97112 and 97530) 
provided on January 7, 2020 through January 23, 2020. 
 
You asked the Plan to pay for the therapeutic procedures and activities. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more 
appropriate CPT code that should be used to bill the services provided. 
 
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 97112 is therapeutic procedure, 1 or more areas, each 15 
minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or 
proprioception for sitting and/or standing activities. 
 
The CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), each 15 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the therapeutic procedures and activities. Our reviewer says 
that CPT codes 97112 and 97530 do not meet criteria for billing or reimbursement consideration. Our reviewer 
found the Physical Therapy note does not include all criteria for these codes.  The documentation includes 
manual and gait training only.  Documentation also does not support 23 minutes spent performing this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapeutic procedures and activities have not been met. Therefore, we 
decided that the Plan does not have to pay for therapeutic procedures and activities (97112 and 97530) 
provided on January 7, 2020 through January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the outpatient surgery services provided on 
April 23, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you cannot afford the charges. 
The Plan denied your request. The Plan says the claim was processed correctly with a copay. 
 
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 $200 
copay for outpatient surgery.  
 
You have been asked to pay a $200 copay for the services provided. The services fall within the outpatient 
surgery 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 copay for the outpatient surgery services 
provided on April 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 18, 2018 
through January 20, 2018. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the inpatient admission was medically necessary. The Plan denied your request. The Plan says that this 
care could have been rendered in an outpatient or observation setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably 
expected that the member's necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 18, 2018 through January 20, 2018.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection (67028) and computerized ophthalmic diagnostic 
imaging (92134) provided on January 23, 2020. 
 
You asked the Plan to pay for the injection and imaging. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation did not support the 
services billed. 
 
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 67028 is intravitreal injection of a pharmacologic agent 
(separate procedure). 
 
The CPT Code Manual definition of code 92134 is scanning computerized ophthalmic diagnostic imaging, 
posterior segment, with interpretation and report, unilateral or bilateral; retina.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the injection and imaging. Our reviewer says that CPT codes 
67028 and 92134 do not meet criteria for billing or reimbursement consideration. Our reviewer found the 
procedure report did not include an intravitreal injection of a pharmacologic agent, therefore this service cannot 
be verified as performed.   Also, documentation did not include interpretation report for scanning computerized 
ophthalmic diagnostic imaging, posterior segment with interpretation and report, unilateral or bilateral; retina, 
and again, cannot be verified as performed during this service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injection and imaging have not been met. Therefore, we decided that the 
Plan does not have to pay for an injection (67028) and computerized ophthalmic diagnostic imaging (92134) 
provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee wishes to continue with the 
requested services. The Plan denied your request. The Plan says the home ventilator and supporting services 
can be provided in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment 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-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on September 11, 2020 and underwent a right total hip revision with placement of antibiotic spacer. The enrollee is receiving appropriate care at the present acute care hospital and when considered medically stable by the treating team. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services