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

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you were told you shouldn't 
owe anything. The Plan denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for outpatient surgery.  
 
You have been asked to pay a $275 copayment for each outpatient surgery. 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 outpatient surgery services provided.
Appeal type: Outpatient Mental Health
Decision: Partially Favorable

 
We decided that the Plan has to adjust the copayment for the office visits (99213) provided on July 28, 2020 
and August 18, 2020. We also decided that the Plan does not have to waive the copayment for the psychiatric 
diagnostic evaluation (90792) provided on June 23, 2020. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan says that the copayments have been applied correctly to the services provided. 
 
We decided that the Plan has to adjust the copayment for the office visits (99213).  The Plan contract says 
that the applicable copayment for each Medicare-covered individual visit for outpatient mental health care is 
$20. The record shows that in this case, outpatient mental health care was provided on each date of service. 
However, the Plan applied a $50 copayment to each office visit. The documentation provided does not state 
specifically why a different copayment was applied to these services. Therefore, we decided that the Plan has to 
adjust the copayment from $50 to $20 for the office visits (99213) provided on July 28, 2020 and August 18, 
2020.  
 
 
 
We also decided that the Plan does not have to waive the copayment for the psychiatric diagnostic 
evaluation (90792). Your contract with the Plan clearly says that you must pay a $20 copayment for each 
Medicare-covered individual visit for outpatient mental health care. 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 psychiatric diagnostic evaluation (90792) provided on June 23, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA1/BRCA2 testing. 
 
You asked the Plan to pre-approve BRCA1/BRCA2 testing. 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 medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that BRCA1/BRCA2 testing is only covered for certain 
indications. 
 
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 BRCA1/BRCA2 testing. Our reviewer 
says that the documentation does not support that the requested testing is medically reasonable or necessary. 
Our physician reviewer found you have had no personal history of cancer. You have family history of breast 
cancer in her grandmother and aunt. According to guidelines, BRCA1/BRCA2 genetic analysis is covered for 
individuals with a personal history of breast cancer. Therefore, you do not meet criteria for the requested 
testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BRCA1/BRCA2 testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve BRCA1/BRCA2 testing.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on June 16, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you have never had to pay 
this much before. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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% 
coinsurance for outpatient surgery.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $22,488.93. The total amount you are being asked to pay is $4,497.79 ($22,488.93 x 20% = 
$4,497.79). The correct coinsurance has been applied to the surgery that was provided. An outpatient surgery 
falls within the outpatient surgery 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 
an outpatient surgery provided by a participating provider on June 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bioimpedance spectroscopy services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is at high risk of 
developing lymphedema. The Plan denied your request. The Plan says there is not enough medical evidence to 
show its usefulness for lymphedema to manage the enrollee's treatment. 
 
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 breast cancer. Bioimpedance spectroscopy has been requested to help 
prevent lymphedema. Lymphatic research shows that clinical decision making with bioimpedance spectroscopy 
should be regarded with caution because of moderate reliability. Therefore, the requested services are not 
considered 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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bioimpedance spectroscopy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the durable medical equipment provided. 
 
You asked the Plan to waive the cost share for the services provided. You say that you only used it once and 
then returned the equipment. The Plan denied your request. The Plan says there is no contract provision for 
waiver of the cost share. 
 
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% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the durable 
medical equipment and related 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 cost share 
for the durable medical equipment provided.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copays for the radiology testing provided. 
 
You asked the Plan to waive the copays for the services provided. You say that you cannot afford the copays. 
The Plan denied your request. The Plan says you are responsible for a copay for each service. 
 
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 $110 
copay for each Medicare-covered radiological diagnostic service.  
 
The file shows that you received a transthoracic echocardiography, a duplex scan of extracranial arteries, a 
duplex scan of the lower extremity arteries, and a complete vascular study. You have been asked to pay a $110 
copay for each of the services provided. The services fall within the outpatient diagnostic tests 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 copays for the radiology testing provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the medial branch blocks. The Plan denied your request. The Plan says the 
injection are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are covered for the following 
indications. 
 
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 medial branch blocks. Our reviewer 
says that the requested injections are not medically reasonable and necessary in this case. Our physician 
reviewer found that the provided medical record does not document the duration of the enrollee's pain nor does 
the record document the degree of functional impairment. Physical therapy is mentioned in the record, 
however, the duration and adequacy of the trial of physical is not mentioned. The medical record does not 
address if the enrollee has tried Non-steroidal anti-inflammatory drugs. 
 
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 medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve medial branch blocks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that the care could have been provided without an 
inpatient stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. The record did not show that at the time of inpatient admission the admitting physician reasonably 
expected that the patient's necessary hospital care (including earlier emergency department and/or observation 
 
 
care) would span two midnights. Our physician reviewer found that the enrollee's condition did not meet 
Medicare criteria for acute inpatient hospital care. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the eye exam with refraction (92015) provided to the enrollee. 
 
You asked the Plan to pay for these services. You say that the enrollee was referred to your office by the 
enrollee's primary care provider and that these services should be covered. The Plan denied your request. The 
Plan says that that there is not claim on file for frames with progressive lenses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one routine eye exam with refraction and dilation is covered per year. 
 
We looked at the file and the Plan's rules. The Plan?s Evidence of Coverage indicates that one eye exam with 
refraction is covered per year. Based on this information, we decided that the Plan's rules for coverage of these 
 
 
services have been met. Therefore, we decided that the Plan has to pay for the eye exam with refraction 
(92015) provided to the enrollee.  
 
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 emergency department visit for the evaluation and 
management of a patient (99285) provided. 
 
You asked the Plan to pay for the emergency department visit. You say that CPT code 99285 was down coded 
in error. Please see attached ER records and review E/M code 99285 for full payment. The Plan denied your 
request. The Plan says the documentation submitted did not support the code selection and a more appropriate 
evaluation and management level has been assigned. 
 
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 99285 is  emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. 
 
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 emergency department visit. Our 
reviewer says that the documentation supports billing code 99283 is correct based on the reviewed 
documentation. Our physician reviewer found the enrollee was noted to have injury to a previously partially 
amputated toe with distal end gangrenous, granulated tissue.  Care included plain film imaging, ABI testing, 
laboratory tests, vascular and podiatry consultations. Review of the documentation supports an expanded 
problem focused examination and medical decision making of moderate complexity.   
 
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 emergency department visit have not been met. Therefore, we decided that 
the Plan does not have to pay for emergency department visit for the evaluation and management of a patient 
(99285) provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9501) provided. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code S9501 has a status indicator of I 
and is not valid for Medicare purposes. 
 
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 CPT code S9501 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9501 has a status indicator of I. This means that CPT code S9501 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9501) 
provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits. 
 
You asked the Plan to pre-approve ten (10) additional physical therapy visits. You say that your treating 
therapist believes more physical therapy is needed for you to walk without a walker. The Plan denied your 
request. The Plan says the additional physical therapy is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 ten (10) additional physical therapy 
visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is 
not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for 
this condition and it does not appear that your functional level requires the unique skills of a professional 
therapist to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist or under the supervision of a therapist. You have had home exercise instruction. 
The  specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ten (10) additional physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve ten (10) additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health stay provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the inpatient mental health stay. You say that you would like this claim 
reprocessed and approved for payment. 
 The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
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 the inpatient mental health stay provided  by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 5, 2020 by an out of 
network provider. 
 
You asked the Plan to pay for the nursing facility care service. You say that the facility should have requested 
authorization. The Plan denied your request. The Plan says you did not request 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 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 medical services provided on June 5, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids (V5261) provided. 
 
You asked the Plan to pre-approve the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says the hearing aids are not covered out of network. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from network providers.  
 
We looked at the file, and the Plan's rules. The hearing aids were obtained from a non-contracted provider. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pre-approve hearing aids (V5261) provided.