Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lesional removal and related services 
provided from July 22, 2020, through July 24, 2020. 
 
You asked the Plan to waive the copayment for the lesional removal and related services. You say that you are 
disputing the $295 copayment. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment for all other outpatient services including observation and outpatient surgical services not provided 
in an ambulatory surgical center. 
 
You have been asked to pay a $295 copayment for the lesional removal and related services. The lesional 
removal and related services fall 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 the lesional removal and related services provided from July 22, 2020, through July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift chair recliner. 
 
You asked the Plan to pre-approve a lift chair recliner. You say that the 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 a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
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 a lift chair recliner. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found based on the medical records provided 
there is no documentation that you meet the coverage criteria. The provided medical records do not document 
that you are completely incapable of standing up from a regular armchair or any chair in your home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a lift chair recliner have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a lift chair recliner.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for needle electromyography provided on March 25, 2020. 
 
You asked the Plan to pay for needle electromyography. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says 95886-59, 2 units, was not supported in the medical records. 
 
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 95886 is needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List 
separately in addition to code for primary procedure).  
 
We find that CPT code 95886 is not supported in the medical record. Specifically, five or more muscles 
studied, per extremity, is required and only four per extremity are noted. Based on this information, we decided 
that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the 
Plan does not have to pay for needle electromyography provided on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
services provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a 
participating provider on April 29, 2020. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to get a splinter out 
but left without having the splinter removed. 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 $30 
copayment for urgently needed services.  
 
You have been asked to pay a $30 copayment for an urgent care visit. Since an urgent care visit was provided, 
the correct copayment has been applied. An urgent care visit falls within the urgently needed 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 an urgent care visit provided by a participating 
provider on April 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 6, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 6, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart, without 
contrast material, with quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart with calcium without contrast. 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. 
 
The Plan follows Medicare rules. Medicare rules say that CCT and CCTA are covered under certain 
circumstances. 
 
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 a CT scan of the heart with calcium 
without contrast. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
in this setting screening cardiac CT scanning with calcium scoring is not recommended and has not been shown 
to improve cardiac outcome incremental to that achievable based on treatment guided by standard clinical risk 
profiling and basic lipid analysis alone. Moreover you are already being treated with high dose-statin and 
ezetimibe so treatment would likely not change regardless of results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CT scan of the heart with calcium without contrast have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
heart, without contrast material, with quantitative evaluation of coronary calcium (75571).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213) provided 
June 1, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you do not believe you should 
have to pay the provider for a phone call. This was not a visit and the provider only asked questions and 
rescheduled your appointment. The Plan denied your request. The Plan says this claim processed with the 
correct copayment applied per the Evidence of Coverage. 
 
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 $40 
copayment per specialist visit for Physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $40 copayment per specialist visit for the office visit. the office visit falls 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 copayment for the outpatient office visit (99213) provided June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the services requested are medically necessary. 
The Plan denied your request. The Plan says the service you are requesting is available within the Plan's 
network with multiple participating providers available. 
 
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 
the office visit to be 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 physician's services provided on April 8, 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 April 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the lumbar-sacral orthosis provided on May 20, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically 
necessary. The Plan denied your request. The Plan says that the records do not show the orthosis was applied or 
dispensed to the enrollee on the billed date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does contain a valid proof of delivery for the orthosis provided in this case.  The record shows an 
enrollee signed purchase order and warranty form for a lumbar sacral orthosis (L0650), signed May 20, 2020. 
Therefore, we decided that the Plan has to pay for the lumbar-sacral orthosis provided on May 20, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested CardioMEMS HF 
System is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
System 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 a CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer 
found the enrollee has preserved left ventricular function and predominantly pre-capillary pulmonary 
hypertension which is severe with a high transpulmonary gradient. CardioMEMS has been studied and found to 
be safe and effective in decreasing recurrent hospitalization in larger clinical trials of patients with congestive 
heart failure due to left ventricular failure. There is very limited data on its use in severe pulmonary 
hypertension patients in the absence of left ventricular failure and only one small pilot study of 26 patients to 
date with the recommendation that further larger clinical studies are necessary before its general and 
widespread use can be recommended for this indication. Based on current published data, and the lack of large 
clinical trials of its use for this clinical indication, the CardioMEMS device has not yet been shown to be safe 
and effective or medically necessary for the management of pulmonary hypertension in the absence of left 
ventricular failure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care could be received in another setting, such as a skilled nursing facility, outpatient 
setting or home health care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular 
physician evaluation. The enrollees care needs can be met at a lower level of care (ex. SNF/SAR). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 16, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 the requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 36415, 81001, 81025, and 
85025. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 36415, 81001, 81025, and 85025 are not supported in the medical record. Specifically, 
charges for laboratory services furnished to outpatients of IHS providers are combined with all other outpatient 
charges for the same date of service and should be reported under revenue code 0510 (clinic visit) on TOB 13X 
(tribal hospitals and hospital-based clinics) and Payment is made on the outpatient per visit AIR (OMB rate). 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 36415, 
81001, 81025, and 85025 provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on January 7, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation submitted does not support that these services were performed with 
blood sampling. Blood specimen collection is by venipuncture; however, the submitted medical records contain 
discrepancies between the reported specimen type collected and the billed code. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 
80173 provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee deserves the best outcome to 
return to his prior level of function. The Plan denied your request. The Plan says the services the enrollee 
requires can be obtained at a subacute level of care. 
 
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 physician 
reviewer found that the enrollee was admitted to the current acute care hospital with chest pain, aspiration 
pneumonia, respiratory failure, congestive heart failure, dysphagia, and pulmonary edema. He was treated with 
intubation, but has transitioned to trach collar. The records show that this enrollee is improving. Although he 
requires additional short term acute care for additional stabilization and treatment, this is likely to take less than 
25 days, and could safely be completed at the current facility. The enrollee does not require services at the 
LTACH that are not already available at the current setting.  Therefore, this request for LTACH services will 
be considered 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure and provided on June 
15, 2020. 
 
You asked the Plan to pay for the unspecified preventive procedure. You say that your dental benefit has a $0 
deductible, $2,000 annual maximum and no waiting period. You say that there should be coverage for the 
evaluations. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 pay for the 
unspecified preventive procedure and provided on June 15, 2020.