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

We decided that the Plan does not have to waive the copayment for the visit provided on July 5, 2020. 
 
You asked the Plan to waive the copayment for the visit. You say that this provider is your PCP, so you 
shouldn't have this copayment. The Plan denied your request. The Plan says this provider was not your PCP on 
the date of service in question, so the copayment was charged 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 $40 
copayment for visits with a specialist (i.e., a provider who is not your PCP).  
 
Records show that you had this home visit on July 5, 2020.  Records also show that you did not call your Plan 
to request that this provider be listed as your PCP until July 8, 2020, three days after this home visit. As a 
result, you have been asked to pay a $40 copayment for the visit. The visit falls within the visits with a 
specialist (i.e., a provider who is not your PCP) 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 visit provided on July 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with CT (78815). 
 
You asked the Plan to pre-approve the PET with CT. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says there is no documentation of a 
biopsy done or any abnormal findings to indicate concerns for a diagnosis of cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PET with CT. Our reviewer says 
that there is not supporting documentation to justify the study ordered. Our physician reviewer found a PET CT 
scan has been ordered for reasons that are not clear from the notes provided. There is no evidence of a 
documented mass that would indicate the need for the PET scan for localization or characterization. 
 
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 PET with CT have not been met. Therefore, we decided that the Plan does 
not have to pre-approve PET with CT (78815).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2750) and core buildup (D2950) provided on 
January 13, 2020. 
 
You asked the Plan to pay for the crown (D2750) and core buildup (D2950). You say that you didn't learn you 
were in the wrong plan until the crown was denied. You say that it wasn?t your fault you were put in the wrong 
plan and the denial should be reconsidered. The Plan denied your request. The Plan says the service 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
(D2750) and core buildup (D2950) provided on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the longer the rehab takes, the more difficult it will 
be to move forward. The Plan denied your request. The Plan says the enrollee does not have a complex medical 
condition that requires frequent physician monitoring, or face-to-face physician visits three times a week. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for right total hip replacement. She had a transection of femoral artery and required vascular 
surgery to repair the injury. Medical problems are stable. There are no identified problems that need inpatient 
medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that this enrollee will be able to fully participate in and benefit from the 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 22, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent in the 
comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the 
Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for sterile gauze pads (A6219) received on May 15 and 
May 27, 2020. 
 
You asked the Plan to waive the coinsurance for sterile gauze pads. You say that you shouldn't pay for these 
charges because they were based off a COVID-19 diagnosis. The Plan denied your request. The Plan says that 
the correct coinsurance was applied. 
 
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. Specifically, the Plan has not forwarded to us the Explanation of Benefits (EOB) 
pertaining to the dates of service May 15 and May 27, 2020. We are unable to verify that the coinsurance for 
sterile gauze pads was assessed correctly by the Plan. Therefore, we decided that the Plan has to waive the 
coinsurance for sterile gauze pads (A6219) received on May 15 and May 27, 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 pre-approve home health services provided by a registered nurse 
(G0299) or a licensed practical nurse (G0300). 
 
You asked the Plan to pre-approve home health services. You say that you need home health services. The Plan 
denied your request. The Plan says rules for home health care have not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. We noted that a certification and plan of care signed by the doctor in 
charge of your care was not provided. Based on this information, we decided that Medicare rules for coverage 
of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
home health services provided by a registered nurse (G0299) or a licensed practical nurse (G0300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on April 1, 2020. 
 
You asked the Plan to pay for the anesthesia 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 anesthesia services provided on April 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on April 7, 2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says all services provided by out-of-network providers requires prior authorization 
except for emergency, urgent care or dialysis while temporarily out of the plan's service area. 
 
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 a psychiatric diagnostic evaluation with medical services 
provided on April 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided to the enrollee 
by a network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is an appropriate candidate for 
pulmonary rehabilitation. The Plan denied your request. The Plan says rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a breast lift. 
 
You asked the Plan to pre-approve the procedure. You say that the entire treatment team has recommended this 
procedure. The Plan denied your request. The Plan says this is considered cosmetic. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you underwent a previous breast reduction, and are now requesting a lift due statements of pain 
due to rashes and irritation due to skin excess. However, the medical documentation does not support evidence 
of chronic rashes/infection as the result of excess skin of the lower part of the breasts.  The main complaint 
documented in the medical records is deflation of the breasts and poor appearance. The only conservative 
management reported is topical moisturizers to help rejuvenate the skin. There is insufficient evidence that you 
have chronic rashes treated with typical dermatologic management, like antifungal medications or other 
medications to combat infection. The requested procedure should be considered cosmetic. 
 
 
 
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 a breast lift.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Mirena intrauterine device (58300 and J7298) provided on 
August 22, 2019. 
 
You asked the Plan to pay for the Mirena intrauterine device. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says per Medicare guidelines, these 
codes are Non-covered services for Medicare purposes, as codes J7298 and 58300 are assigned a status code N 
= Non-covered service. 
 
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing 
conception (contraception) are not considered medically reasonable and necessary.  
 
Records show that the requested service is primarily for the purpose of contraception. The documentation does 
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for 
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for a 
Mirena intrauterine device (58300 and J7298) provided on August 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Promethazine. 
 
You asked the Plan to pre-approve Promethazine. The Plan denied your request. The Plan says the medication 
does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Promethazine.  
 
Benefits for Promethazine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The 
Plan denied your request. The Plan says that total electric hospital beds are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on April 30, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on April 30, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for a foam dressing (HCPCS A6214) provided to the enrollee on February 
21, 2020. 
 
You asked the Plan to pay for the dressing. You say that  The Plan denied your request. The Plan says that 
HCPCS A6213 is a more appropriate code to use in this case. 
 
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 HCPCS code A6214 is "Foam dressing, wound cover, sterile, 
pad size more than 48 sq in, with any size adhesive border, each dressing." 
 
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 dressing. Our reviewers says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the 
documentation states the wound was 72 square inches, which would make the code appropriate. 
 
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 dressing have been met. Therefore, we decided that the Plan has to pay for a 
foam dressing (HCPCS A6214) provided to the enrollee on February 21, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 71045) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II 
code. 
 
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, 
the column two code is denied, and the column one code is eligible for payment. Procedure code 71045 is part 
of an edit pair with procedure code 36561. Procedure code 36561 is a column one code, and procedure code 
71045 is a column two code. Procedure code 36561 has been paid for this date of service, which means that 
procedure code 71045 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for 
the services (CPT 71045) provided.