Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the radiation therapy services you received 
from March 6, 2020 through March 30, 2020. 
 
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you had 
authorization for these services so they should be covered. The Plan denied your request. The Plan says you 
were charged this coinsurance correctly. The plan says that no copayment was applied for the MRI, rather these 
charges represent coinsurance for the radiation therapy. 
 
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 20% 
coinsurance for therapeutic radiology services, including radiation.  
 
You have been asked to pay 20% coinsurance for the radiation therapy 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 coinsurance for the radiation therapy services you received from March 6, 2020 through March 30, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve additional non-emergent transportation trips. You say that you are 
requesting review of denial of services. The Plan denied your request. The Plan says you exhausted your 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of twenty-four (24) one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. The 25th trip and 
beyond is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve additional 
non-emergent transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not have clinical conditions that cannot be treated in the current hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include oxygen supplementation chest tube care, serial radiological imaging, surveillance laboratory 
studies, and therapy services. The documentation does not support that the enrollee in this case requires 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the 
diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion spacer. 
 
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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic 
back pain but no documented spinal instability. The requested Superion spacer is considered experimental, as 
more research is needed to show its safety and efficacy. The services are 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 Superion spacer.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve endovenous ablation therapy of incompetent vein, extremity, 
inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated (CPT 
Code 36473 x 2). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the services are not necessary. 
 
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 pre-approve the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the services are medically necessary, because the patients has recurrent cellulitis due to venous 
insufficiency. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and 
monitoring, percutaneous, mechanochemical; first vein treated (CPT Code 36473 x 2).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic radiology services (76377) performed January 2, 
2020. 
 
You asked the Plan to pay for the radiology services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says insufficient records were provided to support the billed CPT code. 
 
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 76377 is 3D rendering with interpretation and reporting 
of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image 
post-processing under concurrent supervision; requiring image post-processing on an independent workstation. 
 
We find that CPT code 76377 is not supported in the medical record. Specifically, the records provided do not 
demonstrate that a 3D rendering was performed. The plan has requested additional records to support the 
service but none were provided. Based on this information, we decided that Medicare rules for coverage of the 
radiology services have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic 
radiology services (76377) performed January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mandibular partial denture provided on March 19, 2019 
by an OON provider. 
 
You asked the Plan to pay for the mandibular partial denture. You say that you feel the claim should be paid at 
the allowed amount, regardless of the provider's contract status, because you are comfortable with this 
provider's service. The Plan denied your request. The Plan says the treating provider is OON. The Plan also 
says that the services provided were non-emergent. 
 
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, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
mandibular partial denture provided on March 19, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoe heel pads (L3485 LT, RT) rendered by the out of 
network (OON) provider on September 11, 2019. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says the items were rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no 
exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have 
to pay for the shoe heel pads (L3485 LT, RT) rendered by the out of network (OON) provider on  
September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 6, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are 
statutorily excluded.  
 
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status 
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 6, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
April 7, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment per visit to a specialist.  
 
You have been asked to pay a $40 copayment for the telehealth specialist office visit provided. The record 
shows that this service was provided to you by your physician via telephone. Additionally, the telemedicine 
reminder brochure issued to enrollees with an effective date of March 9, 2020, indicates that telemedicine 
service availability has expanded to specialists. Regular specialist cost sharing will apply to all expanded 
telemedicine services not related to COVID-19 testing. 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 office visit (99213) provided on April 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular stress test (93016, 93018) rendered by the 
out of network (OON) provider on February 3, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the cardiovascular stress test (93016, 93018) rendered by the out of network (OON) provider on 
February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the LifeVest you received on January 11, 
2020. 
 
You asked the Plan to waive the coinsurance for the LifeVest. You say that you thought your insurance would 
cover this item at 100%.  You stated that you shouldn't have to pay for this because you didn't need the device. 
The Plan denied your request. The Plan says you were charged this coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the LifeVest. The LifeVest falls within the durable medical 
equipment 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. This cost sharing applies regardless of whether or not you believe you need the device. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the LifeVest you received on January 11, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services (A0427 and A0425) provided on August 
6, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the member could 
have been safely transported by another type of motor vehicle. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 ambulance services. Our reviewer says 
that there is no physical examination documented. There were no medical interventions documented en route.   
The enrollee could have safely been transported for hospital evaluation by other means. Our physician reviewer 
found medical necessity is not supported. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance services (A0427 and A0425) provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out of network 
(OON) provider on April 21, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the psychotherapy (90832) rendered by the out of network (OON) provider on April 21, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound of the pelvis (76856) and the 
ultrasound behind the abdominal cavity (76770) provided on February 19, 2020. 
 
You asked the Plan to waive the copayment for the ultrasounds. You say that you would like reconsideration 
because this was one procedure and the copayment should only be $100. The Plan denied your request. The 
Plan says you received two ultrasounds on the billed date of service and there is a $100 copayment per 
ultrasound. 
 
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 Radiological Diagnostic Services.  
 
You have been asked to pay $69.12 for the pelvic ultrasound. The allowed amount for this ultrasound is 
$69.12. Because the allowable amount is less than the copayment, you are only responsible for this much. The 
ultrasound of the abdominal cavity has an allowed amount of $110.62, therefore you are responsible for a $100 
copayment for this service. 
 
You have been asked to pay a $169.12 for the ultrasounds. The ultrasounds fall within the Radiological 
Diagnostic 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 the ultrasound of the 
pelvis (76856) and the ultrasound behind the abdominal cavity (76770) provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on February 24, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) 
provider on February 24, 2020.
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 the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional level requires an intensive rehabilitation therapy program provided in an 
IRF. 
 
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.