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

 
We decided that the Plan does not have to waive the copayment for a cataract surgery provided on May 26, 
2020. 
 
You asked the Plan to waive the copayment for a cataract surgery. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the claim 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 $200 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You have been asked to pay a $200 copayment for a cataract surgery. A cataract surgery falls within the 
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 
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 a cataract surgery provided on 
May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0651, E0657) provided 
on August 5, 2020. 
 
You asked the Plan to pay for a pneumatic compression device. You say that this should be covered. The Plan 
denied your request. The Plan says the records do not show that the enrollee had sufficient conservative 
therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that six-month trial of conservative therapy 
demonstrating failed response to treatment is required for coverage of a pneumatic compression device. 
 
We looked at the file and Medicare rules. The records do not show that the enrollee failed six months of 
conservative therapy. Based on this information, we decided that Medicare rules for coverage of a pneumatic 
compression device have not been met. Therefore, we decided that the Plan does not have to pay for a 
pneumatic compression device (E0651, E0657) provided on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate predictive screening testing provided to the enrollee 
on April 16, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient 
are not a benefit. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have had a prior elevated PSA and prior negative prostate biopsy. A year later, 
the enrollee underwent a GU evaluation, where no concerning symptoms were reported. Physical examination 
noted a large, but non-tender and non-nodular prostate. A repeat PSA was not yet available. As such, persistent 
or elevated cancer risk factors were not documented and the Conform MDx test was not coverable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for prostate predictive screening testing provided to the enrollee on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reclining chair. 
 
You asked the Plan to pre-approve a reclining chair. You say that the requested item is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reclining chair.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral appliance to treat sleep apnea. 
 
You asked the Plan to pre-approve the oral appliance. You say that the enrollee has sever apnea and does not 
tolerate CPAP. The Plan denied your request. The Plan says that coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that oral appliances to treat sleep apnea are only covered 
under certain medical 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 oral appliance. Our physician 
reviewer found that the enrollee has severe obstructive sleep apnea (OSA) according to a sleep study in 2017, 
with AHI greater than 30.  The patient has signed an undated affidavit indicating intolerance of CPAP.  MAD 
is a reasonable and medically necessary treatment for this patient's OSA. 
 
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 oral appliance have been met. Therefore, we decided that the Plan has to 
pre-approve an oral appliance to treat sleep apnea.  
 
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) and hospital discharge 
(99238) provided on August 4, 2020, through August 5, 2020. 
 
You asked the Plan to pay for hospital care and discharge. You say that the service was medically necessary. 
The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within 
twelve months or one calendar year from the date when the services were rendered. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for hospital care and discharge was not filed until September 14, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) and hospital 
discharge (99238) provided on August 4, 2020, through August 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D0272, D1110, D0120) provided on 
September 23, 2020. 
 
You asked the Plan to pay for dental services. You say that these services should be covered. The Plan denied 
your request. The Plan says the yearly allowance for dental services has been met. 
 
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, it covers only a $235 allowance each 
year for dental services. The record shows that you used the full $235 prior to receiving the services at issue. 
Therefore, we decided that the Plan does not have to pay for dental services (D0272, D1110, D0120) provided 
on September 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the breast ultrasound rendered on August 
18, 2020. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 $1,000 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the all other Medicare-covered 
diagnostic radiology services (not including x-rays) benefit category. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This 
cost sharing is a contractual obligation that had not been met at the time these services were received on August 
18, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the breast ultrasound 
rendered on August 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on October 5, 
2020, October 7, 2020 and October 9, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you weren't told you had a $30 
copayment. You say that you don't have the extra income to pay. 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 $30 
copayment for physical therapy from an in-network specialist's office or comprehensive outpatient rehab facility. 
  
You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is $90 
($30/visit x 3 visits = $90). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on October 5, 2020, 
October 7, 2020 and October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus shot received on July 24, 2020. 
 
You asked the Plan to pay for the Tetanus shot. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus shot. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus shot. 
Therefore, we decided that the Plan does not have to pay for the Tetanus shot received on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological exam provided on August 18, 2020 
along with an intravitreal injection (67028). 
 
You asked the Plan to pay for the medical eye exam. You say that this is separately payable. The Plan denied 
your request. The Plan says the eye exam provided is included in the global fee for the intravitreal injection. 
 
The Plan follows Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We asked our coding 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 medical eye exam. Our reviewer says 
that the documentation does not support separate payment for the medical eye exam. Our coding reviewer 
found the medical records provided do not include sufficient information to validate billing CPT 92014 as a 
separate service from the minor procedure (CPT 67028) also performed on the same date of service. 
 
 
 
 
 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medical eye exam have not been met. Therefore, we decided that the Plan 
does not have to pay for the ophthalmological exam provided on August 18, 2020 along with an intravitreal 
injection (67028).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental. More research is needed to show safety 
and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 7, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 lab work provided on October 7, 2020 by an out of 
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) with 
the watchman device (33340). 
 
You asked the Plan to pre-approve LAAC with the watchman device. You say that the services are necessary. 
The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria has not been met. 
 
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 LAAC with the watchman device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the Watchman device should still be considered investigational in enrollees 
who are tolerating anticoagulation without significant bleeding side effects (skin bruising and scratching 
generally not considered serious) or evidence of recurrent strokes, such as with this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of LAAC with the watchman device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous left atrial appendage closure (LAAC) with the 
watchman device (33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on May 7, 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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the telehealth services 
rendered on May 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and 2 dental extractions to be performed 
by an oral surgeon. 
 
You asked the Plan to pre-approve a consultation and 2 dental extractions to be performed by an oral surgeon. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
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 pre-approve a 
consultation and 2 dental extractions to be performed by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical preparation or creation of recipient site by excision 
of open wounds (15002, 15003, 15004, 15005) provided April 16, 2020. 
 
You asked the Plan to pay for surgical preparation or creation of recipient site by excision of open wounds. 
You say that you would like reconsideration based on the medical records provided. The Plan denied your 
request. The Plan says the billed codes cannot be verified. 
 
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 asked our Coder 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 surgical preparation or creation of recipient 
site by excision of open wounds. Our reviewer says that the billed codes are not supported by the medical 
records provided. Our Coder reviewer found that the operative report documents wound preparation of a 
chronic wound bed. CPT codes 15002, 15003, 15004, and 15005 are used to describe the initial services related 
to preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft or for 
negative pressure wound therapy. Per CPT guidelines these codes would not be reported for removal of 
nonviable tissue/debris in a chronic wound. 
 
We looked at this Coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgical preparation or creation of recipient site by excision of open wounds 
have not been met. Therefore, we decided that the Plan does not have to pay for surgical preparation or creation 
of recipient site by excision of open wounds (15002, 15003, 15004, 15005) provided April 16, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF care provided from December 20, 
2019, to December 31, 2019. 
 
You asked the Plan to waive the copayment for the SNF care. You say that all out of pocket deductibles were 
met, and this bill should have been covered. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. 
 
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 $0 
copayment per day for days 1 to 20 and a $167.50 copayment per day for days 21 to 100 for Skilled nursing 
facility (SNF) care.  
 
You have been asked to pay $0 copayment per day for days 1 to 20 and a $167.50 copayment per day for days 
21 to 100 for SNF care. SNF care falls within the Skilled nursing facility (SNF) care benefit category. You 
have only been asked to pay a copayment of $$1,675 because this amount met the $4,900 maximum out-of-
pocket amount for 2019. 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 SNF care provided 
from December 20, 2019, to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 29, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on June 29, 2020.