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

We decided that the Plan does not have to pay for the bone density scan rendered on August 30, 2019. 
 
You asked the Plan to pay for these services. You say that you would like the claim reprocessed. The Plan 
denied your request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, a bone density scan, was requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for 
the bone density scan rendered on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe presumptive drug tests (80307) provided on August 13, 2020, by an out-of-network (OON) provider.You asked the Plan to pay fordrug tests. You say that you performed a service on a specimen sent to you by another provider.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 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 forthe presumptive drug tests (80307) provided on August 13, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home polysomnography (PSG). 
 
You asked the Plan to pre-approve home polysomnography. 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 home PSG 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 home polysomnography. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our physician reviewer found the enrollee has known obstructive sleep apnea and has been on continuous 
positive airway pressure therapy for years. The machine is no longer functioning properly. The clinical notes 
do not indicate that there have been major changes in the enrollee's health status or weight. Therefore, a new 
PSG is not medically necessary. The appropriate action is to replace (or repair) the PAP device. A new PSG or 
titration study would be necessary only if the enrollee continues to have problems when back on CPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home polysomnography have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home polysomnography (PSG).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services you require can safely be received at a different setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean injection procedure with CPT code G0260.You asked the Plan to pre-approveCPT code G0260. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the G code is only denied for the physician because it is not appropriate for the surgeon to bill with this code. The Plan says the claim, when received from the surgery center, will be paid with this code; however, this code is not payable under the physician fee schedule.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.CPT code G0260 has a status indicator of "E" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment for these codes are excluded from the physician fee schedule by regulation. This code can only be billed by the facility where the enrollee will have the approved procedure.Therefore, we decided that the Plan does not have to pre-approvean injection procedure with CPT code G0260.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for 2 specialist office visits (99203 and 
99214) on January 13 and January 28, 2020. 
 
You asked the Plan to waive the copayments for 2 specialist office visits. You say that these charges were 
incurred due to confusion over a disenrollment issue. The Plan denied your request. The Plan says the correct 
copayments were 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 $50 
copayment for consultation, diagnosis, and treatment by a specialist.  
 
You have been asked to pay $100, or a $50 copayment for each one of 2 specialist office visits. Specialist 
office visits fall within the "Physician/Practitioner services, including doctor's office 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 copayments for 2 specialist office visits (99203 and 99214) on January 13 
and January 28, 2020.  
 
Your complaint about receiving erroneous information about disenrollment is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency department visit  (99285) provided February 14, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you are requesting the Plan base 
payment on the presenting complaint and overall care provided to the enrollee and not on the final diagnostic 
code assigned to the claim. The Plan denied your request. The Plan says the level of service for this evaluation 
and management code was reduced based on the diagnostic information on the claim. 
 
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 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 records provided supports CPT code 99285. Our physician reviewer found 
documentation submitted supports a comprehensive history, consisting of 10 + system review, a comprehensive 
exam consisting of general multi-system exam (8 or more systems), and medical decision making of high 
complexity consisting of complexity of data reviewed; labs, chest x-ray, EKG, medicine section ordered or 
reviewed, independent visualization of image, tracing or specimen (emergency room physician documents 
interpretation of EKG in absence of Cardiologist).  
 
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 been met. Therefore, we decided that the 
Plan has to pay for the emergency department visit  (99285) provided February 14, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 30, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's services. 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 physician's services provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus immunization rendered on August 3, 2019. 
 
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. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the tetanus immunization rendered on August 3, 
2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve physical therapy. You submitted the order for physical therapy. The Plan 
denied your request. The Plan says you must use network providers to get medical care and services. 
 
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 
physical therapy to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on July 24, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you cannot afford this copayment 
because you are on disability. The Plan denied your request. The Plan says the correct copayment 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 $60 
copayment for outpatient diagnostic tests/in-network/ultrasound.  
 
You have been asked to pay a $60 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests/in-network/ultrasound 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 by a participating provider on July 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided on 
February 26, 2020. 
 
You asked the Plan to waive the copayment for extracapsular cataract removal. You say that you disagree with 
the charges because your doctor recommends the procedure. 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 $275 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  
 
You received extracapsular cataract removal on February 26, 2020. Extracapsular cataract removal is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.  
 
You have been asked to pay a $275 copayment for extracapsular cataract removal. Extracapsular cataract 
removal 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 
extracapsular cataract removal provided on February 26, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil tab 200mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the medication does not fall under the Part B benefits. 
 
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 Modafinil tab 200mg for 
the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on February 19, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
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 these services was not filed until August 11, 2020. A valid Waiver of 
Liability (WOL) was not received until September 16, 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 the testing services rendered on February 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision exams you had on May 13, 2020, 
and June 24, 2020. 
 
You asked the Plan to waive the copayments. You say that you were told that this would be covered. The Plan 
denied your request. The Plan says you are responsible for 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 $35 
copayment for each Medicare-covered eye exam to diagnose and treat diseases and conditions of the eye.  
 
Review of the file shows that you vision exams on May 13, 2020, and June 24, 2020. Per your contract with the 
Plan, there is a $35 copayment for each vision exam. However, the Medicare allowed amount for each exam 
was $23.93. Since the allowed amount was less than the $35 copayment, you have been asked to pay the lesser 
amount for each exam. 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 vision exams you had on 
May 13, 2020, and June 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an assisted living facility 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says assisted living communities do not require skilled nursing care; therefore, it is not 
covered. 
 
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. 
 
An assisted living facility does not provide skilled services. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to an assisted living facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level neurologist. 
 
You asked the Plan to pre-approve these services. You say that the requested provider has the best doctors. The 
Plan denied your request. The Plan says the tertiary level of care is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show 
that you have a diagnosis of amyotrophic lateral sclerosis (ALS). An evaluation by a tertiary provider is not 
expected to provide any meaningful changes in the overall management of your diagnosis. Given that your 
diagnosis has been confirmed, a tertiary evaluation is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level neurologist.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. The Plan denied your request. The Plan says the enrollee has not failed Zoledronic acid, or have a history of osteoporosis fracture.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our physician reviewer found that the enrollee has a history of osteoporosis. The Plan requires a trial of Zoledronic acid, or have a history of osteoporosis fracture before they will approve the requested drug. In this case, the enrolleehas not tried and failed thePlan's requirements. There is no documentation provided indicatingthat the Pan's required drugwould likely be less effective, or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.