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

 
We decided that the Plan does not have to waive the copayment for the tendon sheath injection and 
arthrocentesis provided on June 9, 2020 and June 23, 2020. 
 
You asked the Plan to waive the copayment for the tendon sheath injection and arthrocentesis. You say that the 
injections were part of your office visit. You say that you shouldn?t be charged a copayment for a procedure 
done in a treatment room in a hospital. The Plan denied your request. The Plan says the copayments 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 $300 
copayment for surgery services at an in-network outpatient hospital. 
 
You have been asked to pay a total of $469.48 for the tendon sheath injection and arthrocentesis.  
 
Date of 
Service 
Service Allowed Amount Standard 
Copayment 
Member Liability 
June 9, 2020 Tendon Sheath Injection $234.74 $300 $234.74 
June 23, 2020 Arthrocentesis $234.74 $300 $234.74 
TOTAL:    $469.48 
 
The tendon sheath injection and arthrocentesis fall within the "Outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers" benefit category. The tendon sheath injection 
and arthrocentesis are considered surgical procedures that were billed by the hospital.   
 
 
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 tendon sheath injection and arthrocentesis provided on 
June 9, 2020 and June 23, 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 you cannot walk or leave the bed by yourself. The 
Plan denied your request. The Plan says your  rehab needs are not complex, and you do not need a rehab 
physician visit 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 physician reviewer found 
that you were admitted to the acute hospital for treatment of bile duct cancer. Your medical conditions are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a 
need for physical and occupational therapy, there is no need for an intensive rehabilitation program. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve implantable loop recorder. You say that you are appealing. The Plan denied 
your request. The Plan says the denial of authorization for this service is correct, because the records do not 
show that the enrollee had a fainting event thought to be caused by an irregular heartbeat that was frequent 
enough to be found on a portable monitor. 
 
The Plan follows Medicare rules. Medicare rules say that an implantable loop recorder is used when syncope is 
thought to be cardiac-related, but is too infrequent to be detected by either a Holter monitor or traditional pre-
symptom memory loop recorder. 
 
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 implantable loop recorder. Our 
reviewer says that the enrollee does not meet the Medicare criteria for an implantable loop recorder. Our 
physician reviewer found the enrollee denied any cardiac rhythm related symptoms in records, the 
documentation does not show what would necessitate this device placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable loop recorder have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an implantable loop recorder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested service. You say that clinical research has shown the safety 
and efficacy of the requested device. The Plan denied your request. The Plan says it is not identified as 
accepted for the proposed use. 
 
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 requested service. Our physician 
reviewer found that the enrollee has a history of COPD, diabetes, hyperlipidemia, hypertension, coronary artery 
disease, and congestive heart failure with reduced LV ejection fraction requiring hospital admission. In this 
circumstance, therapy change based on data obtained from a CardioMEMS device has been demonstrated in 
only one randomized prospective trial to help reduce hospital readmission compared to standard medical 
therapy. Concerns have been raised about potential bias in this trial calling into question the results. The 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities, and not 
recommended in current guidelines for the treatment of heart failure.  Therefore, the device is considered 
experimental and investigational. 
 
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 requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on July 18, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you were left unattended and were 
not checked on. You say that you shouldn't have to pay the 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" 
benefit category. The records show that you were treated in the ER. 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 ER visit provided on July 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable cardiac loop recorder for the enrollee. 
 
You asked the Plan to pre-approve an implantable cardiac loop recorder. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the records do not show that the enrollee had a 
fainting event thought to be caused by an irregular heart rhythm that was not frequent enough to be found on a 
portable monitor. 
 
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 an implantable cardiac loop recorder. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Based on the records the patient has mild dizziness but no syncope. In this circumstance if additional 
monitoring for a dysrhythmia were thought to be medically necessary then prolonged Holter monitoring or 
extended external cardiac event monitoring would be appropriate and considered standard accepted practice in 
the medical community. Since there is no documented unexplained syncope or cryptogenic stroke, the records 
do not support the medical necessity for routine monitoring with an implantable loop recorder. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for an implantable cardiac loop 
recorder. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable cardiac loop recorder have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an implantable cardiac loop recorder for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided 
on August 3, 2020. 
 
You asked the Plan to pay for limited oral evaluation. You say that you should not be liable because you were 
not aware services would be done. The Plan denied your request. The Plan says you have exhausted your 
maximum benefit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The plan covers ones 
emergency diagnostic exam per year. 
 
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. Records indicate you received an emergency diagnostic exam on July 
28, 2020, this means you have exhausted your benefit maximum for this service. Therefore, we decided that the 
Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested services. You say that clinical research has shown the safety 
and efficacy of the device. The Plan denied your request. The Plan says this service is not identified as 
generally accepted for the proposed use. 
 
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 requested services. Our physician 
reviewer found that the enrollee has non-ischemic cardiomyopathy with ejection fraction of 20-25%. She is on 
full guideline directed medical therapy with continued symptoms and 2 recent hospitalizations for congestive 
heart failure. She is being considered for chronic inotropic IV therapy as well. The efficacy of the 
CardioMEMS heart failure system remains uncertain at this time. Further clinical study is needed for determine 
the efficacy and safety of this device. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee and 
billed under code G0482. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare has specific documentation 
requirements for this type of testing. In this case, the records provided are insufficient to show the 
documentation required by Medicare was present to show this testing was medically necessary. Medicare rules 
for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for 
drug testing provided to the enrollee and billed under code G0482.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular stimulator. 
 
You asked the Plan to pre-approve the requested service. You say that the goal is to alleviate the enrollee's 
current pain, and increase their ability to participate in day to day activities. The Plan denied your request. The 
Plan says it is a new agent of unknown use and efficacy. 
 
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 requested service. Our physician 
reviewer found that the enrollee has several chronic pain complaints. She has wide-spread osteoarthritis. She 
takes Ultram, Nalfon and Lidoderm patches for pain. The requested service is considered electroacupuncture. 
This is considered experimental/investigational.  Therefore, the request service is considered not medically 
reasonable or necessary. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested service have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an auricular stimulator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the chest and the x-ray of the ribs you had on June 1, 2020.

You asked the Plan to waive the copayment for the x-rays. You say that you already paid for these services, so you don't know why you are getting a bill. The Plan denied your request. The Plan says you were appropriately charged two $20 copayments because you had two separate x-ray services.

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 $20 copayment for each Medicare-covered standard x-ray service. 

You have been asked to pay a $20 copayment for each of the x-rays, for a total of $40. 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 x-ray of the chest and the x-ray of the ribs you had on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic shoes provided on July 2, 2020.

You asked the Plan to waive the coinsurance for diabetic shoes. You say that you have never been charged for diabetic shoes in the past. 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 20% coinsurance for therapeutic shoes and inserts.

You received diabetic shoes on July 2, 2020. The total allowed amount is $243.11 and 20% of that is $48.63.  

You have been asked to pay the total coinsurance amount of $48.63 for diabetic shoes. Diabetic shoes fall within the diabetic self-management training, diabetic 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 coinsurance for diabetic shoes provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the services you received from an out-of-network podiatrist on July 20, 2020.

You asked the Plan to waive the deductible for the out-of-network podiatry services. You say that you don't understand why you were billed the full amount instead of just a $45 copayment. The Plan denied your request. The Plan says this deductible was assessed correctly. The Plan says that because this provider is out-of-network, the deductible applies.

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 there is a $1300 deductible for out-of-network services. 

Because this podiatrist is an out-of-network provider, the annual deductible applies to this service.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1300 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network podiatry services was received on July 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the services you received from an out-of-network podiatrist on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit you had on 
July 23, 2020. 
 
You asked the Plan to waive the copayment for the primary care office visit. You say that you went to the 
doctor's for your annual physical exam, which has no copayment. The Plan denied your request. The Plan says 
you already exhausted your annual physical exam benefit.  You had an annual physical exam with your 
primary care doctor on January 13, 2020, so any other visits for the year with this provider would be subject to 
a copayment. 
 
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 $20 
copayment for physician visits.  
 
You have been asked to pay a $20 copayment for the primary care office visit. Because you had already 
exhausted your annual physical exam benefit, this visit falls within the physician visits 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 primary care office visit you had on July 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 14, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have never been charged in the 
past and disagree with the charges. 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 $0 
copayment for each diagnostic mammograms and a $110 copayment for radiological diagnostic services.  
 
You have been asked to pay a $0 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic services 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 an ultrasound provided on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair received from March 16, 2020 to March 23, 
2020. 
 
You asked the Plan to pay for the lift chair. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the item was used in another place other than the enrollee's residence. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the lift chair was used in an on campus outpatient hospital, (place of service 22). Therefore, 
we decided that the Plan does not have to pay for the lift chair received from March 16, 2020 to March 23, 
2020.
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 this was a routine mammogram. 
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 $160 
copayment for each Medicare-covered radiological diagnostic service.  
 
You have been asked to pay $135.78, which is less than the standard $160 copayment for the ultrasound. The 
ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit 
category. The records show that you were not charged for the screening mammogram. The ultrasound is 
considered a diagnostic test, which applies a copayment.  
 
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.