Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen system purchased on June 22, 2020. 
 
You asked the Plan to pay for the system. You say that this piece of equipment was required by your doctor for 
use at night. The Plan denied your request. The Plan says an oxygen system purchase is not a covered service 
by Medicare guidelines 
 
The Plan must follow Medicare rules. Medicare rules say that purchase oxygen equipment is not covered. 
 
This type of equipment must be rented in order to be covered. The equipment was purchased. Based on this 
information, we decided that Medicare rules for coverage of the system have not been met. Therefore, we 
decided that the Plan does not have to pay for an oxygen system purchased on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $20 copayment for physician services provided on April 
27, 2020. 
 
You asked the Plan to waive this service. You say that this was Covid related and there should be no 
copayment. The Plan denied your request. The Plan says the medical records provided by your physician do not 
show this was Covid related. 
 
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 
copayment for physician services. 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 $20 copayment for physician services provided 
on April 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a shoulder immobilizer (L3660) provided 
July 13, 2020. 
 
You asked the Plan to waive the coinsurance for the shoulder immobilizer. You say that the brace was poor 
quality and the cost-sharing should be waived. The Plan denied your request. The Plan says the correct 
coinsurance was 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 Durable Medical Equipment.  
 
You have been asked to pay a 20% coinsurance for the shoulder immobilizer. The shoulder immobilizer falls 
within the Durable Medical Equipment 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 a shoulder immobilizer (L3660) provided July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardiology office visit you had on July 
9, 2020. 
 
You asked the Plan to waive the copayment for the cardiology visit. You say that you shouldn't have to pay a 
copayment for a follow-up visit to your cardiac catheterization. The Plan denied your request. The Plan says 
you were charged this copayment 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 $35 
copayment for specialist visits.  
 
You have been asked to pay a $35 copayment for the cardiology visit. Medicare indicates that follow-up visits 
from a cardiac catheterization (CPT code 93458) are not included in the cost for the procedure itself. Providers 
are permitted to charge copayments for follow-up visits for cardiac catheterization. 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 cardiology office visit you had on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit on July 8, 2020. 
 
You asked the Plan to waive the deductible for the office visit. You say that the deductible should be waived. 
The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
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 $750 deductible. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for 
the office visit. The plan applied the $189.21 cost of the office visit to your deductible. This cost sharing is a 
contractual obligation that had not been met at the time the office visit was received on July 8, 2020. Therefore, 
we decided that the Plan does not have to waive the deductible for an office visit on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit (99205) provided May 21, 2020. 
 
You asked the Plan to pay for the new patient office visit. You say that the patient saw a new physician that has 
a different specialty. The Plan denied your request. The Plan says a new patient visit has already been billed for 
this enrollee in the past 3 years. 
 
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 99205 is not supported in the medical record. Specifically, the records show the 
enrollee saw another cardiologist from the same group within the past 3 years for a new patient visit. Based on 
this information, we decided that Medicare rules for coverage of the new patient office visit have not been met. 
Therefore, we decided that the Plan does not have to pay for a new patient office visit (99205) provided May 
21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on May 28, 2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says the service was rendered by a provider who does not accept the Medicare 
assignment. The provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a 
psychiatric diagnostic evaluation with medical services provided on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and coinsurance for an 
injection provided by a participating provider on May 28, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for an office visit and an injection. You say that 
you do not make enough a month to pay for the additional charges. The Plan denied your request. The Plan 
says the correct copayment and 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 $35 
copayment and a 20% coinsurance for physician/practitioner services/in-network/specialist and Medicare Part 
B prescription drugs/in-network.  
 
You have been asked to pay a $35 copayment for an office visit and a 20% coinsurance of the allowed amount 
for an injection. The total allowed amount is $1,027 for an injection. The total amount you are being asked to 
pay for an injection is $205.40 (1,027 x 20% = $205.40). The total amount you are being asked to pay is 
$240.40 ($205.40 + $35 = $240.40). An office visit falls within the physician/practitioner services/in-
network/specialist benefit category. An injection falls within the Medicare Part B prescription drugs/in-network 
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 office visit and coinsurance 
for an injection provided by a participating provider on May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
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.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT scan of the heart for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records show that a same study or test has been done. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee has known 
prior mild-moderate CAD on CTA and several risk factors for CAD. Though her recent nuclear scan was 
negative for ischemia, she has persistent debilitating symptoms which can be consistent with ischemia 
especially in women who can often present with atypical symptoms. Given the persistent symptoms and the 
prior known CAD, a repeat CT angiogram to assess for anatomic progression of coronary artery disease is 
reasonable and medically necessary in this clinical situation. This would also obviate the need for more 
invasive coronary angiography in this intermediate risk patient with a prior negative functional study and is a 
reasonable and prudent next step in her evaluation. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
CT scan of the heart for 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided on February 5, 2020 to 
February 10, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic services. You say that when you arrived for the appointment 
they advised that they were not contracted with the plan but they had received authorization. You were not 
advised that you could receive a bill later. The Plan denied your request. The Plan says enrollees must receive 
their medical services from an in-network provider with the exception being urgent or emergent services. Non-
emergent services with non-contracted providers require prior authorization before services being rendered. 
 
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 chiropractic services provided on February 5, 
2020 to February 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nerve block procedure (64490, 64491). 
 
You asked the Plan to pre-approve the nerve block procedure. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that nerve block procedures are covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nerve block procedure. Our 
reviewer says that the nerve block procedure is not medically necessary. Our physician reviewer found the 
record shows that the enrollee complains of numbness and tingling, not pain. In this case the member has 
radiculopathy, which is not a covered indication. 
 
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 nerve block procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a nerve block procedure (64490, 64491).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on June 23, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on June 23, 2020.
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 the SNF services. You say that the progress note supports the need for SNF 
care. The Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF per submitted 
documentation.  The enrollee does not have complex wound care or other ongoing SNF level skilled nursing 
need in the submitted documentation. The enrollee's functional level does not require skilled therapy services 
with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide 
medically necessary and reasonable treatment only in a SNF. The enrollee does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, 
the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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 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: 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 enrollee clearly exceeds the CMS 
established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says 
transfer to a LTACH is not medically necessary at this time. 
 
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 enrollee still requires acute hospital level of care services, and is receiving 
appropriate care at the present acute care hospital. Our reviewer found that the enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services 
are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and 
able to be furnished safely and effectively only on an inpatient basis. 
 
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.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT) with intensity modulated 
radiotherapy (IMRT) planning. 
 
You asked the Plan to pre-approve stereotactic body radiotherapy (SBRT) with intensity modulated 
radiotherapy (IMRT) planning. You say that the requested stereotactic body radiotherapy (SBRT) with 
intensity modulated radiotherapy (IMRT) planning is medically necessary. The Plan denied your request. The 
Plan says that the requested stereotactic body radiotherapy (SBRT) with intensity modulated radiotherapy 
(IMRT) planning is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve stereotactic body radiotherapy (SBRT) 
with intensity modulated radiotherapy (IMRT) planning. Our reviewer says that the requested stereotactic body 
radiotherapy (SBRT) with intensity modulated radiotherapy (IMRT) planning is medically necessary. Our 
physician reviewer found stereotactic body radiotherapy (SBRT) with intensity modulated radiotherapy 
(IMRT) may be considered as an alternative to EBRT in patients with oligometastatic bone metastases in 
whom the primary is controlled and who have an estimated survival of greater than six months. This enrollee's 
prognosis is likely greater than 6 months. SBRT is generally well tolerated and not associated with significant 
toxicities. It is not proton therapy. The service is reasonable and 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 stereotactic body radiotherapy (SBRT) with intensity modulated radiotherapy 
(IMRT) planning have been met. Therefore, we decided that the Plan has to pre-approve stereotactic body 
radiotherapy (SBRT) with intensity modulated radiotherapy (IMRT) planning.  
 
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 a home visit (99350) provided. 
 
You asked the Plan to pay for the home visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the services rendered were not provided at the enrollee's home. 
 
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 99350 is Home visit for the evaluation and management 
of an established patient. 
 
We find that CPT code 99350 is not supported in the medical record. Specifically, the record shows the 
services were provided at an assisted living facility and not the enrollee's private residence. Based on this 
information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we 
decided that the Plan does not have to pay for a home visit (99350) provided.