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

 
We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
February 17, 2020. 
 
You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration 
because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating 
room through the duration of the procedure. The Plan denied your request. The Plan says payment for this 
service is included in the DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pump operation and assembly have not been met. Specifically, payment for this service is 
included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, 
we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on 
February 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar interspinous device insertion (22867). 
 
You asked the Plan to pre-approve the interspinous spacer device insertion. You say that the service is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. The 
procedure at issue is not supported by current medical literature. 
 
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 interspinous spacer device insertion. 
Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the 
device is still considered investigation for the enrollee's condition. 
 
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 interspinous spacer device insertion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lumbar interspinous device insertion (22867).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services provided  on September 27, 2019 to 
September 29, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for diagnostic services. You say that this was incorrectly denied. 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 diagnostic services provided  on September 27, 
2019 to September 29, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to reimburse you the allowance for your paid fitness center membership of 2019. 
 
You asked the Plan to reimburse you the allowance for your paid fitness center membership. You say that you 
submitted your request timely. The Plan denied your request. The Plan says that your request was received 
untimely in March 2020. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers non-
participating fitness clubs benefits when payment requests are submitted within 90 days of the end of the 
calendar year. 
 
The Plans rules for coverage of gym benefits have been met because the enrollee requested reimbursement on 
March 8, 2020, which was denied on March 14, 2020. The request was submitted before the 90-day deadline of 
March 31, 2020. Therefore, we decided that the Plan has to reimburse you the allowance for the allowance 
towards your paid fitness center membership.  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services coded 72170 provided on April 19, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial 
The Plan denied your request. The Plan says the requested services are not separately payable. 
 
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, we have confirmed that code 72170 
for the x-ray services has a bundled relationship with code 73502 and cannot be paid as billed. This code 
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 72170 provided on 
April 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 20, 
2019. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you thought that the 
ambulance was free and disagree with the charges because you were waiting for a ride. 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 $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray provided on March 9, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you would like your used insurance money of 
$1,000 as well as the additional $150 returned because you are still in pain after several visits. The Plan denied 
your request. The Plan says benefits for this service are limited to one time per 36 month period. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, panoramic x-ray is limited to 1 per 36 
months. The record shows that you received a panoramic x-ray on January 13, 2020 and your panoramic x-ray 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray 
provided on March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care from February 18, 2020 through February 28, 
2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says that the stay is not medically necessary. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. It appears that the plans contracted delegate was provided the records for this 
admission and has failed to forward them to support the decision to deny based on no medical necessity. 
Therefore, we decided that the Plan has to pay for inpatient hospital care from February 18, 2020 through 
February 28, 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: Favorable

 
We decided that the Plan has to adjust the enrollee liability to a $50 copayment for the brachytherapy (C2616) 
provided on June 18, 2019. 
 
You asked the Plan to adjust the enrollee liability to a $50 copayment. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the 
coinsurance has been applied correctly to the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $50 copayment for each in network outpatient hospital 
visit for radiation therapy.  
 
The Plan says you must pay a 20% coinsurance for the Medicare Part B drug provided. However, upon review 
of this procedure and the Plan contract, we find that this service falls into the radiation therapy benefit category 
and not the Part B drug category. You cannot be asked to pay more than a $50 copayment for this service. 
Therefore, we decided that the Plan has to adjust the enrollee liability to a $50 copayment for the brachytherapy 
(C2616) provided on June 18, 2019.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on review of the medical records, the enrollee does not meet the CMS 
coverage criteria for an IRF admission based on lack of medical intensity and nursing needs. There is no 
evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. The 
documentation does not support that there is a need for an intensive therapy program with 3 hours a day at the 
current level of function and an interdisciplinary approach to rehab care. The patient will benefit from 
continuing physical therapy (PT) and occupational therapy (OT) and still needs therapies to get stronger but not 
in an IRF. This enrollee does not meet the CMS coverage criteria for an IRF admission. The patient's rehab 
needs can be met in an alternate, less intense setting such as in continuation of in-home therapies.  
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the skilled nursing facility. You say that SNF services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing facility. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
 
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 skilled nursing facility have not been met. Therefore, we decided that the 
Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical intensity and nursing needs. There is no evidence of medical 
issues that require monitoring by an inpatient rehab physician three times a week. The documentation does not 
support that there is a need for an intensive therapy program with 3 hours a day at the current level of function 
(with dependency in all mobility and activities of daily living (ADLs), non-weight bearing (NWB) in two (2) 
extremities with Dementia that was impacting participation in addition) and an interdisciplinary approach to 
rehab care. You may benefit from continuing physical therapy (PT) and occupational therapy (OT) for care 
giver training. You do not meet the CMS coverage criteria for an IRF admission. Your rehab needs can be met 
in an alternate, less intense setting such as in a skilled nursing facility (SNF). 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp (J0881). 
 
You asked the Plan to pre-approve Aranesp. You say that Aranesp is medically necessary. The Plan denied 
your request. The Plan says a trial of Retacrit is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Aranesp. Our reviewer says that 
Aranesp is not medically necessary. Our physician reviewer found the plan has approved Retacrit. There has 
been no trial yet of Retacrit. Based on the medical records provided there is no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp (J0881).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for Medicare coverage of IRF care. 
 
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 there is no evidence of medical issues that require monitoring by an inpatient 
rehabilitation physician three times a week. The documentation does not support that there is a need for an 
intensive therapy program with 3 hours a day at the current level of function and an interdisciplinary approach 
to care. The patient may benefit from continuing therapy but does not meet Medicare coverage criteria for an 
IRF admission. 
 
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: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost-sharing charges for a cystourethroscopy. We decided that the 
Plan does not have to reduce the cost-sharing charges for a cystourethroscopy to the amount you requested. 
 
You asked the Plan to waive the copayment for a cystourethroscopy. You say that you should not owe an 
ambulatory surgical copayment because the surgery took place at your doctors office. The Plan says that the 
claims were processed correctly and you are being charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for a cystourethroscopy from $200 to 
$45.  
 
The record shows that a cystourethroscopy provided on May 8, 2020 was provided a specialists office. 
Therefore, you cannot be asked to pay more than the $45 copayment. Therefore, we decided that the Plan has 
to reduce the cost-sharing charges for a cystourethroscopy from $200 to $45. 
 
We also decided that the Plan does not have to reduce the cost-sharing charges for a cystourethroscopy 
to the amount you requested. 
 
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 specialist services. Therefore, we decided that the Plan does not have to waive the copayment 
for a cystourethroscopy. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 0008U provided on February 
25, 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 requested services 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 laboratory 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 
laboratory services coded 0008U provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urgent care services provided on January 5, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the urgent care visit. You say that you went to this clinic because your PCP's 
office was closed. You have gone to this provider in the past and had it covered with your copayment. You feel 
that this should not be denied. The Plan denied your request. The Plan says there is no evidence that your 
medical condition on the date of service was urgent. 
 
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 file does not show that there 
were no in-network urgent care facilities available in your area on the date in question. In-area urgent care is 
only covered if no network provider is available. The Plan did not pre-approve the item/service at issue. We 
found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the 
Plan does not have to pay for the urgent care services provided on January 5, 2020 by an out of network (OON) 
provider.