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

 We decided that the Plan does not have to pay for Cervical, multiple post collar, occipital/mandibular supports 
(L0180) provided October 22, 2019. 
 
You asked the Plan to pay for the orthosis. You say that you are sending additional medical records as proof of 
medical necessity. You ask for review of all submitted documents and process the claim accordingly for 
payment. The Plan denied your request. The Plan says the billed supply code cannot be verified. 
 
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 not contain an itemized shipping/billing invoice or proof of delivery for the supplies provided 
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for Cervical, multiple post collar, 
occipital/mandibular supports (L0180) provided October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the duplex scan provided on February 19, 
2020. 
 
You asked the Plan to waive the copayment for the duplex scan. You say that you have never had a pay such a 
copayment before. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
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 20% 
coinsurance for Medicare-covered diagnostic procedures and tests.  
 
You have been asked to pay $168.70 which is 20% of the allowed amount for the duplex scan. The allowed 
amount is $843.48. ($843.48 x 20% = $168.70). The duplex scan falls within the Outpatient diagnostic tests 
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the duplex scan provided on February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interspinous process stabilization device. 
 
You asked the Plan to pre-approve interspinous process stabilization device. 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 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 interspinous process stabilization 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has persistent low back pain extending into 
the bilateral legs. The requested device is experimental. More research is needed to show safety and efficacy. 
Therefore, the enrollee does not meet criteria for the requested 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 interspinous process stabilization device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve interspinous process stabilization device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 22, 2020 and January 29, 2020.
You asked the Plan to pay for the dental services. You say that you were not advised you wouldn't receive reimbursement if the dentist opted out of Medicare. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that 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 the dental services provided on January 22, 2020 and January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs rendered on 
January 23, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is a financial 
hardship. The Plan denied your request. The Plan says the coinsurance was 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 20% 
coinsurance for chemotherapy drugs.  
 
Review of the file shows that you received chemotherapy drugs on January 23, 2020. You have been asked to 
pay a 20% coinsurance for these services. These services fall within the chemotherapy drugs 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 the chemotherapy drugs rendered on January 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
March 11, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We 
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan 
does not have to pay for outpatient mental health care provided to the enrollee on March 11, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99283, A9270) 
provided February 8, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care 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 
emergency room visit (99283, A9270) provided February 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on October 5, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found based on the medical records provided there is no documentation that supports an established relationship between the ordering physician and the 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on October 5, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2330) for tooth #11. 
 
You asked the Plan to pre-approve the resin-based composite for tooth #11. You say that chemotherapy has 
weakened the enamel on your tooth. You say that you need to get all of the teeth that were denied fixed for the 
hairline fracture alone the gum line. The Plan denied your request. The Plan says the request exceeds allowable 
limits for this service. 
 
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. The records show that you received coverage for a resin-based 
composite for tooth #11 on March 1, 2018. This means that your benefit for a resin-based composite on tooth 
#11 is currently exhausted. Therefore, we decided that the Plan does not have to pre-approve a resin-based 
composite (D2330) for tooth #11.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99281) provided 
February 24, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived. The Plan denied your request. The Plan says the correct copayment 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care 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 
emergency room visit (99281) provided February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on June 6, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 pay for the drug testing rendered on June 6, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve catheterization surgery services (procedure codes 36222, 36223, 36224, 36225, 36226).
You asked the Plan to pre-approve surgical services. You say that you are appealing. The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because the risk of injury is significant while the indications for this surgery remain insufficient.
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 surgical services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has an indwelling left middle cerebral artery (MCA) stent which was placed after thrombectomy 6 months ago. Antiplatelet therapy has been instituted. The request for a catheter angiogram is reasonable as a diagnostic procedure as well as providing access in case any intervention concerning the stent is necessary. While symptoms have not changed in 6 months the request for optimal visualization of the involved artery via catheter is reasonable and indicated together with the ability to change the stent or adjust it. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgical services have been met. Therefore, we decided that the Plan has to pre-approve catheterization surgery services (procedure codes 36222, 36223, 36224, 36225, 36226).
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 (33289, C2624). 
 
You asked the Plan to pre-approve a CardioMEMS HF System. 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 a CardioMEMS HF System. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this circumstance therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met since the device should still be considered experimental or investigational. 
 
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 (33289, C2624).
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 you would like reconsideration because 
the member is in immediate need of LTACH services for respiratory management, nutritional support, overall 
system management to prevent readmission. The Plan denied your request. The Plan says the member is 
receiving the appropriate care and does not require a transfer to a LTACH. 
 
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 does not require services at the LTACH that are not available at the acute 
care hospital where she 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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy services. 
 
You asked the Plan to pre-approve 6 additional physical therapy services. 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 must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 6 additional physical therapy services. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found the enrollee has made some progress in 
therapy and the enrollee's functional deficits do not indicate the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively 
be performed only by a therapist, or under the supervision of a therapist. The patient has had therapy and was 
trained in a home exercise program. The requested services are not part of a maintenance program and the 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or 
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 
Therefore, the enrollee does not meet criteria for the requested 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 6 additional physical therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on December 21, 2019.
You asked the Plan to pay for train of four testing. You say that this should be paid at the in-network level. The Plan denied your request. The Plan says this service is not separately payable.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on December 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital observation stay provided from February 27, 2020 
to February 28, 2020. 
 
You asked the Plan to pay for the hospital observation stay. The Plan denied your request. The Plan says that 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan. 
 
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 a hospital observation stay provided from February 27, 2020 to 
February 28, 2020.