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

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
September 25, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you tried to see your PCP for care for 
a urinary tract infection, however, your PCP would not see you because you refused to wear a mask in the 
office.  As a result, you had to go to the ER instead. The Plan denied your request. The Plan says you were 
charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room visits.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason 
for the ER visit. 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 (ER) visit 
you had on September 25, 2020.
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services 
with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve COSENTYX Pen Injection. 
 
You asked the Plan to pre-approve COSENTYX Pen Injection. You say that the services are necessary. The 
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a 
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 
coverage. 
 
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 COSENTYX Pen Injection.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve these 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. Medicare rules say that PET 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has no cancer diagnosis but 
scans have shown non-specific enlargement of the external iliac nodes. There is no strong suspicion for 
malignancy. The requested PET/CT is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional visits for physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that you need therapy to avoid additional 
amputation. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because the Plan approved 6 additional visits and further visits beyond this are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 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 therapy has been provided and improvement has been documented. A 
home exercise program and lifestyle changes are indicated at this point. It has not been demonstrated that a 
maintenance program is medically reasonable and necessary at this time. 
 
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 additional visits for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for train of four testing (TOF) testing to monitor the depth of 
muscle relaxation during surgery (95999) provided to the enrollee.
 
You asked the Plan to pay for this surgery. You say that the Plan should pay this claim. The Plan denied your 
request. The Plan states that the payment for train of four testing (TOF) coded as 95999, does not meet 
Medicare billing criteria. Medicare guidelines say that this item or service is considered a bundled procedure as 
the cost is included in the cost of the primary procedure. Under Medicare guidelines, your request is not a 
covered benefit because Medicare does not make separate payment for this service.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case code 95999 cannot be paid as billed due 
to its bundled relationship with the primary procedure code. Code 95999 cannot be billed separately. Medicare 
billing criteria are not met. Therefore, we decided that the Plan does not have to pay for train of four testing 
(TOF) (95999) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventative dental services (D1110, D0120) provided on 
August 4, 2020. 
 
You asked the Plan to pay for the preventative dental services. You say that you would like this claim 
reprocessed and approved for payment under your supplemental benefit. The Plan denied your request. The 
Plan says the maximum benefit amount has been met for this type of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the 
preventative dental services when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that you previously exhausted your 2020 $200 
allowance for dental services you received on January 30, 2020. Based on this information, we decided that the 
Plan's rules for coverage of the preventative dental services have not been met. Therefore, we decided that the 
Plan does not have to pay for the preventative dental services (D1110, D0120) provided on August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9330) provided. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 looked at the file and Medicare rules. In this case, CPT code S9330 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy (S9330) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the digital breast tomosynthesis rendered on July 29, 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 77061 is not payable. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes. 
 
We looked at the file and Medicare rules. The provider billed procedure code 77061. This code has a status 
indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay 
for the digital breast tomosynthesis rendered on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living services provided on August 3, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the rendering facility is also out-of-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 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 assisted living services provided on August 3, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Contour Test Strips. 
 
You asked the Plan to pre-approve the Contour Test Strips. You say that the requested items are medically 
necessary for treatment of the enrollee's diabetes. The Plan denied your request. The Plan says that the items 
being requested are not a Plan preferred brand. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. The rules say that plans must provide a clear and accurate description of any applicable limitations 
associated with use or receipt of benefits.  The rules also say that enrollees must retain access to all medically 
necessary items, including non-preferred brands.  
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Explanation of Coverage (EOC) provided did not clearly 
describe that they have specific brands or manufacturers who the enrollee is limited to use for diabetic supplies 
or durable medical equipment. The documentation provided does not indicate that the items are being requested 
from an out of network durable medical equipment provider, nor has the provider shown that their network 
durable medical equipment providers are able to provide all medically necessary brands for the enrollee's 
existing unit. The Plan has not substantiated their denial reason, as the limitation they are leaning on does not 
appear to be valid based on the enrollee's contract. Therefore, we decided that the Plan has to pre-approve 
Contour Test Strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on July 7, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for cataract surgery. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 cataract surgery provided on July 7, 2020 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Genicular block radiofrequency ablation (RFA) 
(64450). 
 
You asked the Plan to pre-approve Genicular block RFA. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 Genicular block RFA. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence is not strong enough and guideline recommendations are not 
supportive enough to recommend genicular blocks for chronic knee pain at this time. Therefore, this request for 
such will be considered 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 Genicular block RFA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Genicular block radiofrequency ablation (RFA) (64450).
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. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription 
coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the discharge day management services billed with code 99239. 
 
You asked the Plan to pay for the discharge management services. You say that the records support the billed 
services. The Plan denied your request. The Plan says there is no documentation of the time spent. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, the discharge note does not 
document the time spent providing these services. Based on this information, we decided that Medicare rules 
for coverage of the discharge management services have not been met. Therefore, we decided that the Plan 
does not have to pay for the discharge day management services billed with code 
99239.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high activity knee control frame (L5930). 
 
You asked the Plan to pre-approve a high activity knee control frame. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that a high activity knee control frame (L5930) is 
covered for beneficiaries whose functional level is 4. 
 
We looked at the file and Medicare rules. The file shows the enrollee is at a K3 functional level. Medicare only 
covers a high activity knee control frame (L5930) for beneficiaries whose functional level is 4.  Therefore, we 
decided that the Plan does not have to pre-approve a high activity knee control frame (L5930).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 8, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you are being charged a $65 
copayment and your copayment should be less. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged 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 $40 
copayment for specialist visits.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac rehabilitation and other medical services to be 
provided out of area (OOA). 
 
You asked the Plan to pre-approve the requested OOA services. You say that you are going to temporarily 
reside in Florida for the winter with your daughter. You indicate that you need to continue your cardiac rehab 
and other medical services during this time and feel that it should be covered due to medical necessity. The 
Plan denied your request. The Plan says your policy does not offer coverage for OOA care in this situation; 
however, you will have a travel benefit feature in your Plan as of January 1, 2021. Once that is in effect, you 
may receive non-urgent services while OOA. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file and Medicare rules. We find that the requested services are not deemed to be urgently 
needed OOA care. A requirement to be considered urgently needed is that the services must be due to an 
unforeseen flare-up of a known condition. The need for these services was not unforeseen as they were initiated 
prior to leaving the service area, and it was known that the need would continue while OOA. Although these 
services may be appropriate, there is no provision in your contract for 2020 which would require the Plan to 
approve these services OOA. Therefore, we decided that the Plan does not have to pre-approve cardiac 
rehabilitation and other medical services to be provided out of area (OOA).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration, per visit (up 
to 2 hours) (99601 and 99602) provided. 
 
You asked the Plan to pay for the home infusion services. You say that you are requesting review and 
reconsideration of payment for the services rendered per the physician orders. The Plan denied your request. 
The Plan says invalid procedure code for this service. 
 
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 99601 (2 units) and 99602 is home infusion/specialty 
drug administration, per visit (up to 2 hours). 
 
We find that CPT code 99601 (2 units) and 99602 is not supported in the medical record. Specifically, 
Medicare guidance says procedure codes 99601 and 99602 has a status code of "I". Status code "I" is not valid 
for Medicare purposes. Medicare uses another code for reporting of and payment for these services. Based on 
this information, we decided that Medicare rules for coverage of the home infusion services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration, 
per visit (up to 2 hours) (99601 and 99602) provided.