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

 
We decided that the Plan does not have to pre-approve the LINX procedure. 
 
You asked the Plan to pre-approve the LINX procedure. You say that the LINX procedure is medically 
necessary. The Plan denied your request. The Plan says the LINX procedure 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 LINX procedure. Our reviewer says 
that the LINX procedure is not medically necessary. Our physician reviewer found the enrollee has 
gastroesophageal reflux based on pH testing, but it has been shown to be variable (modest on Day 1; not 
clinically significant on Day 2), and not correlated in available records with acid reflux events. The enrollee has 
at least partial benefit from acid suppression treatment and as such she cannot be considered refractory to 
medical therapy nor can her acid suppression treatment be considered ineffective. LES function has been 
shown to be manometrically normal, and EGD did not demonstrate significant esophagitis. As such, the 
medical necessity of sphincter augmentation is not apparent nor meets criteria for coverage. 
 
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 LINX procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LINX procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic mammogram you had at an 
outpatient hospital facility on June 19, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you do not think you 
should have to pay this bill. The Plan denied your request. The Plan says you were charged this copayment 
correctly.  The Plan says that because the allowed amount for this service ($119.19) is less than your 
copayment responsibility, you are responsible for the full billed 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 $200 
copayment for diagnostic tests and procedures at an outpatient hospital setting.  
 
You have been asked to pay a $200 copayment for the diagnostic mammogram. The diagnostic mammogram 
falls within the diagnostic tests and procedures at an outpatient hospital setting 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 the diagnostic mammogram you had at an outpatient hospital facility 
on June 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on August 10, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician?s services. 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 physician's services provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital services 
you received from March 24, 2020, to April 3, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital services. You say that you 
believe that your charge should be zero for these services. 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 $275 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $275 copayment per day for days 1-6 for the inpatient rehabilitation hospital 
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 inpatient rehabilitation hospital services you 
received from March 24, 2020, to April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dipyridamole injection services coded J1245 provided on 
January 10, 2019. 
 
You asked the Plan to pay for the dipyridamole injection services. 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 supported by the 
documentation. 
 
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 J1245 is injection, dipyridamole, per 10 mg. 
 
We find that CPT code J1245 is not supported in the medical record. Specifically, 6 units of this code were 
billed. The submitted medical records do not support the 6 units that were billed. Based on this information, we 
decided that Medicare rules for coverage of the dipyridamole injection services have not been met. Therefore, 
we decided that the Plan does not have to pay for the dipyridamole injection services coded J1245 provided on 
January 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 9, 2020, 
to July 16, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care after July 8, 2020. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the inpatient services were not medically 
necessary after July 8, 2020. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the presenting set of symptoms were decided to be the enrollee's baseline dementia 
and not requiring additional acute care. The enrollee required medication adjustments, however, these services 
could have been provided at a lower level of care and did not require inpatient services, according to the 
provided notes. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from July 9, 2020, to July 16, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab tests provided on February 7, 2020. 
 
You asked the Plan to pay for the lab tests. You say that the labs were ordered by your primary care physician. 
The Plan denied your request. The Plan says that the services are not payable by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the lab tests by a contract provider. The file does not show that the Plan provided notice 
that the lab tests would not be covered. Under Medicare rules, this means the lab tests is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the lab tests provided on February 7, 2020.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an annual wellness visit provided on April 28, 2020. 
 
You asked the Plan to pay for this service. You say that this visit should be covered by the Plan. The Plan 
denied your request. The Plan says they reviewed the customer service phone call reference by you in the initial 
correspondence. You inquired about the provider in question, as you were told by the doctor?s office to contact 
the Plan to verify if you are covered. The customer service representative verified that this provider is in-
network and assigned this provider as your new PCP. The customer service representative scheduled an 
appointment, at your request. There was no mention of an annual wellness visit on this call. Per your benefits in 
the 2020 Evidence of Coverage, you can only get an annual wellness visit once every calendar year. You 
received annual wellness visit from another provider on February 27, 2020; therefore, the claim for date of 
service April 28, 2020 denied correctly and you are responsible for the full cost of the annual wellness visit. 
 
 
 
 
 
 
 
 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Medicare only covers an annual wellness visit once per year. The 
Plan only covers an annual wellness visit once per year. The benefit was exhausted on February 27, 2020. 
Therefore, the Plan does not have to pay for a second annual wellness visit provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 87150, 87651, 87481, 87491, 
87529, 87591, 87640, 87641, 87653, and 87798 provided on April 2, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 payable. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural 
service. Specifically, the submitted documentation does not indicate which lab tests represent multiple 
organisms; therefore, the appropriate use of the 59 modifiers in the billed codes are not verified. In addition, the 
physician order/laboratory requisition form indicates an AIM UTI Molecular Pathogen Identification Test 
Panel. There is no indication what is included in the panel. Based on this information, we decided that 
Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 87150, 87651, 87481, 87491, 87529, 
87591, 87640, 87641, 87653, and 87798 provided on April 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immediate denture - mandibular (D5140), immediate denture 
- maxillary (D5130) and comprehensive oral evaluation - new or established (D0150) provided on October 22, 
2019. 
 
You asked the Plan to pay for oral evaluation and dentures. You say that you obtained prior authorization. The 
Plan denied your request. The Plan says you self-referred to a non-participating provider who has opted out 
from accepting Medicare payment and is not eligible to be reimbursed for the services provided. 
 
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 
immediate denture - mandibular (D5140), immediate denture - maxillary (D5130) and comprehensive oral 
evaluation - new or established (D0150) provided on October 22, 2019.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to hold you harmless for laboratory services provided on February 25, 2020. 
 
You asked the Plan to hold you harmless for the laboratory services. You say that you would like 
reconsideration because you are not responsible for the providers coding errors. The Plan denied your request. 
The Plan says that these tests are not covered by Medicare. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for the laboratory services by a contract provider. The file does not show that the Plan 
provided notice that the laboratory services would not be covered. Under Medicare rules, this means the 
laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you 
harmless for laboratory services provided on February 25, 2020.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from June 4, 2019 to June 
25, 2019. 
 
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 claims were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line 
on which the first four positions of the HIPPS code match the code submitted on the RAP. 
 
We looked at the file and Medicare rules. The claims were not submitted with the required HIPPS code. 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 home health services rendered from June 4, 
2019 to June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoCycle FES cycling therapy system (E1399). 
 
You asked the Plan to pre-approve the exercise equipment. You say that the claim should be paid. The Plan 
denied your request. The Plan says the Myocycle home FES therapy system is considered exercise equipment 
and is 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-approve MyoCycle FES cycling therapy system (E1399).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent detection (85707) provided on July 10, 2020. 
 
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration 
because this test was medically necessary. The Plan denied your request. The Plan says that there is no 
documentation of immunodeficiency. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the infectious agent detection. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found this test is reasonable as part of a comprehensive workup for longstanding persistent 
gastrointestinal problems. 
 
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 infectious agent detection have been met. Therefore, we decided that the 
Plan has to pay for infectious agent detection (85707) provided on July 10, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5253) provided on February 11, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because you were 
not informed that prior authorization was necessary. The Plan denied your request. The Plan says services 
rendered by out-of-network providers require prior authorization. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when received from a participating provider.  
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. The record indicates that this provider is not in-
network with the Plan. Therefore, we decided that the Plan does not have to pay for hearing aids (V5253) 
provided on February 11, 2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab services provided to you on February 8, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that these services 
are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice 
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on 
February 8, 2020.  
 
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 TITAN functioning finger. 
 
You asked the Plan to pre-approve the TITAN functioning finger. You say that you would like reconsideration 
because the approved Vincent system would be a disservice to you and your progress. The Plan denied your 
request. The Plan says you have already been approved for the Vincent finger system. 
 
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 TITAN functioning finger. Our 
reviewer says that the requested TITAN system is not considered medically reasonable and necessary and 
exceeds your medical needs. Our physician reviewer found there is insufficient evidence in the literature that 
the TITAN would be more appropriate and beneficial for your condition and functional level than the Vincent 
system. 
 
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 TITAN functioning finger have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a TITAN functioning finger.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 31, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that your previous ultrasound did not 
have a cost. You say that you were there for a standard mammogram and didn't know this would carry a $100 
copayment. The Plan denied your request. The Plan says the copayment applied 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 $100 
copayment for an ultrasound.  
 
You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient 
diagnostic tests and therapeutic services and supplies" 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 the ultrasound provided on July 31, 2020.