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

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
chest (71260) provided on September 17, 2020. 
 
You asked the Plan to waive the copayment for the CT scan of the chest. You say that you would like this 
copayment waived. The Plan denied your request. The Plan says the copayment has applied correctly in this 
case. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $200 copayment for complex radiology.  
 
The enrollee has been asked to pay a $200 copayment for the CT scan of the chest. The service provided falls 
within the complex radiology benefit category. This means that the enrollee has been asked to pay the correct 
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to 
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the computed tomography (CT) scan of the chest (71260) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on August 31, 2020. 
 
You asked the Plan to pay for the radiation therapy and planning. You say that you left your home state due to 
COVID-19 and needed the radiation services. The Plan denied your request. The Plan says you did not request 
prior authorization for the out of area services. 
 
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. Radiation treatment is on the Plan's 2020 Prior Authorization 
Requirements Code List. Based on this information, we decided that Medicare rules for coverage of the 
dermatology services have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiation therapy and planning services provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient care provided from August 12, 2020, to August 
13, 2020. 
 
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was 
stable for transfer. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the inpatient care. Our reviewer says that the 
requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the 
treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not 
stable for transfer on any dates of service. The available clinical documentation supports that the enrollee was 
stable for transfer on August 12, 2020, at 4:28 PM. 
 
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 inpatient care have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient care provided from August 12, 2020, to August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental x-rays you received on October 19, 2020. 
 
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is 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 services are not among 
those covered under this benefit. The plan covers only one dental exam and one cleaning per calendar year. 
Dental x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the dental x-rays 
you received on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT gene panel testing provided on August 7, 2020. 
 
You asked the Plan to pay for the Tempus xT gene panel testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The documentation does not include documentation to support that the services rendered were not for screening 
purposes. This means that the Tempus xT gene panel testing at issue in this appeal was requested solely for 
screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that 
the Plan does not have to pay for the Tempus xT gene panel testing provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) provided on 
September 3, 2020. 
 
You asked the Plan to pay for the surgical placement of implant body. You say that this service was medically 
necessary. The Plan denied your request. The Plan says this service is not covered under your dental 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 pay for the 
surgical placement of implant body (D6010) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ECG provided by a participating 
provider on June 10, 2020. 
 
You asked the Plan to waive the copayment for an ECG. You say that you think you shouldn't be charged 
because the battery failed. 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 $40 
copayment for outpatient diagnostic tests/other diagnostic tests.  
 
You have been asked to pay $29.59 which is less than your copayment amount of $40 for an ECG. The correct 
copayment has been applied to the services that were provided. An ECG falls within the outpatient diagnostic 
tests/other diagnostic tests 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 an ECG 
provided by a participating provider on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 13.You asked the Plan to pre-approvethe dental service. You say that the enrollee needs this service.The Plan denied your request. The Plan says core build up is 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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for tooth # 13.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve destruction. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says the use of peripheral nerve destruction for any other indication including 
cervicogenic headache or occipital neuralgia, post-herpetic neuralgia, trigeminal neuralgia, and laser neurolysis 
is not medically necessary. 
 
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 procedure. Our reviewer says that 
the requested procedure is not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, there is no evidence of a clinical picture that is suggestive of sacroiliac injury 
and/or disease. There are not at least three positive exam findings of SI joint dysfunction present on physical 
exam such as: Patrick's test, thigh thrust, SI compression test, Yeoman's test, or Gaenslan's test. The review has 
determined that the requested sacroiliac joint injections 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve peripheral nerve destruction.
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 January 24, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this is supposed to be 
free. 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 outpatient surgery.  
 
You have been asked to pay a $50 copayment for a diagnostic colonoscopy. Evidence was provided to show 
that polyps were found and removed. The rules say that, if during the course of the screening colonoscopy, a 
lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic 
procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls 
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 copayment for a diagnostic 
colonoscopy provided by a participating provider on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe over-bed table (E1399).You asked the Plan to pre-approvethe over-bed table. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the requested equipment is a convenience item and not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvethe over-bed table (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (28485, 28476) provided September 1, 
2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim did not include a valid primary diagnosis. 
 
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 find that CPT code 28485 & 28476 is not supported in the medical record. Specifically, a sequela code 
cannot be listed as the primary, first listed, or principal diagnosis. 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 surgical services (28485, 28476) provided September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a portable oxygen concentrator for the enrollee. 
 
You asked the Plan to pre-approve the concentrator. You say that the current equipment is too heavy to carry 
around. The Plan denied your request. The Plan says that the enrollee's oxygen needs are being met at this time. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
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 concentrator. Our reviewer says that 
the requested concentrator is medically reasonable and necessary. Our physician reviewer found the enrollee 
has interstitial lung disease and requires oxygen during activity at 3L/min with an oxygen conserving device. 
The enrollee has severe back pain and is unable to carry the portable compressed oxygen tanks during activities 
of daily living within and outside the home. This meets Medicare criteria for coverage of a POC.  This is not 
duplicate equipment because the portable tanks do not meet his needs.  A POC is 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 the concentrator have been met. Therefore, we decided that the Plan has to pre-
approve a portable oxygen concentrator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the unspecified 
preventive service (D1999), and the incomplete endodontic therapy (D3332) provided from July 21, 2020, to 
August 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that it is not fair that you are being billed for this 
service. You say that it was out of your control. You say that during the procedure, the dentist determined that 
the tooth was not restorable. You also say that as a result, the dentist did not complete the root canal and you 
are being billed for nothing. The Plan denied your request. The Plan says 1 limited oral evaluation is covered 
per plan year. The Plan says that the frequency limit for this service has been exceeded. The Plan says that the 
unspecified preventive service is not listed as a covered service. The Plan also says that incomplete endodontic 
therapy is 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 frequency limit of 1 limited oral 
evaluation per plan year has been exceeded. The record shows that the Plan paid for this service that you 
received on June 19, 2020. Additionally, the unspecified preventive service and incomplete endodontic therapy 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
the limited oral evaluation (D0140), the unspecified preventive service (D1999), and the incomplete endodontic 
therapy (D3332) provided from July 21, 2020, to August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block for the knee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is lack of evidence regarding the effectiveness of this procedure. 
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure that is the subject of on-going clinical trials. 
Therefore, the requested procedure is considered not 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 the block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a genicular nerve block for the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on October 9, 2020. 
 
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for ophthalmological services provided on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289). 
 
You asked the Plan to pre-approve the insertion of a CardioMEMS device. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a CardioMEMS device. 
Our reviewer says that the requested services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance, a therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy.  Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 
 
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 insertion of a CardioMEMS device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a CardioMEMS device (C2624, 33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam (92004) provided on 
October 6, 2020. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you thought this would be 
covered as a routine eye exam. The Plan denied your request. The Plan says this was a Medicare-covered 
outpatient visit, not a routine eye exam. 
 
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 $45 
copayment for Medicare-covered vision care.  
 
You have been asked to pay a $45 copayment for the medical eye exam. The services provided fall within the 
Medicare-covered vision care benefit category and not the routine vision 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 the medical eye exam (92004) provided on October 6, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) and observation services rendered 
from August 17, 2020 to August 21, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the outpatient services cannot be separately paid. 
 
The Plan must follow Medicare rules. The rules say that inpatient services should be billed on an 11x type of 
bill. 
 
We looked at the file and Medicare rules. The services were billed as inpatient. The outpatient services cannot 
be separately paid. 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 emergency room (ER) and 
observation services rendered from August 17, 2020 to August 21, 2020.