Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit and chest x-ray you had on 
July 9, 2020, at your pulmonologist's office. 
 
You asked the Plan to waive the copayments for the office visit and x-ray. You say that you should not have to 
pay these copayments. The Plan denied your request. The Plan says you were charged these copayments 
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 
copayment for x-rays and a $35 copayment for the office visit you had with your pulmonologist.  
 
You have been asked to pay a $20 copayment for the x-ray and a $35 copayment for the office visit. 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 the office visit and chest x-ray you had on July 9, 2020, at 
your pulmonologist's office.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the equipment transport and setup provided on March 6, 
2020. 
 
You asked the Plan to pay for the transportation and setup (Q0092) of portable x-ray equipment to the skilled 
nursing facility (R0075). You say that the Plan should pay this claim. The Plan denied your request. The Plan 
says in this place of service the claim is not separately reimbursable. 
 
The Plan must follow Medicare rules. Medicare rules say that the technical component of radiology services in 
a SNF, during a covered stay, are not separately payable. 
 
We find that the transportation and set up costs are subject to consolidated billing. Based on this information, 
we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to 
the nursing home (R0075) have not been met. Therefore, we decided that the Plan does not have to pay for the 
equipment transport and setup provided on March 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the chest 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 a LDCT is more appropriate and indicated to screen for lung cancer. 
 
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 a review of the records 
showed no x-ray or CT reports describing a pulmonary nodule in need of followup. Rather, it appears a CT is 
being requested to evaluate for lung cancer in a patient with a 35 pack year history of smoking.  Thus, the 
requested CT of the chest (CPT 71250) is not supported however as the plan has indicated a LDCT (S8032) if 
requested by the referring clinician would be approved. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the chest for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery you had on June 8, 2020 
to June 9, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you shouldn't have to pay 
this copayment because the first surgery didn't work for you. 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 $250 
copayment for each visit to a hospital outpatient surgical department.  
 
You have been asked to pay a $250 copayment for the outpatient surgery. This copayment applies regardless of 
whether or not you are satisfied with the results of the surgery. 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 outpatient surgery you had on June 8, 2020 to June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 23, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the specialist 
charges and you should only owe a $10 copayment not a $35 copayment. 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 $35 
copayment for each specialist visit.  
 
You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit provided on June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve a partial upper denture and a partial lower denture. You say that the 
requested items are necessary. The Plan denied your request. The Plan says the benefit limit has been 
exhausted. Therefore, coverage criteria has not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a partial 
upper denture and a partial lower denture once every 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a partial upper denture and a partial lower denture have not been met. The Plan covers a partial 
upper denture and a partial lower denture once every 5 years. The record shows that you received a partial 
upper denture and a partial lower denture on August 6, 2020. This means that you are not eligible for health 
plan coverage of a partial upper denture and a partial lower denture at this time. Therefore, we decided that the 
Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on May 3, 2020. 
 
You asked the Plan to pay for the electrocardiogram (93010). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says there is no documentation of an interpretation from the rendering 
provider. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only. 
 
We find that CPT code 93010 is not supported in the medical record. Specifically, without a physician's 
interpretation, note, and signature the computer-generated EKG reports do not meet the requirements for the 
professional component of an EKG. Based on this information, we decided that Medicare rules for coverage of 
the electrocardiogram (93010) have not been met. Therefore, we decided that the Plan does not have to pay for 
the electrocardiogram provided on May 3, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyepti. 
 
You asked the Plan to pre-approve Vyepti. You say that the requested Vyepti is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail a CGRP antagonist or inhibitor first. 
 
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 Vyepti. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of a CGRP 
antagonist or inhibitor first before they will approve the requested drug. Based on the documentation provided, 
the member has not tried and/failed a CGRP antagonist or inhibitor first. The member is said to have previously 
taken Aimovig. However, the only reason for discontinuation was a high copay. The records are otherwise 
silent in regards to if the member has tried/failed therapy with this medication. Consequently, it cannot be said 
that the step therapy requirement for coverage has been met. Consequently, it cannot be said that Vyepti would 
be expected to lead to improved clinical outcomes when compared to the formulary alternatives (Aimovig, 
Ajovy, Emgality). In this setting the step therapy requirements for coverage do not otherwise appear to have 
been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyepti have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Vyepti.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), 
power seat elevation (E2300), push handles (K0108), enhanced switch module (K0108) and electric connection 
between controllers (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare coverage criteria for these accessories. 
 
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 the wheelchair accessories. Our 
reviewer says that the E2377 Expandable Controller and E2313 Expandable Controller Harness and E2311 
Electro connect, are not medically necessary because you do not need to operate 3 or more powered seating 
actuators through the drive control, a separate display, other electronic devices, or an attendant control. your 
strength in the left upper limb and functional ability indicate you can control any power options through your 
own switches. Our physician reviewer found the K0108 push handles and Q logic module and the E2300 seat 
elevator are not primarily medical in nature and therefore do not meet  medical necessity criteria. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller (E2377), harness (E2313), power seat elevation 
(E2300), push handles (K0108), enhanced switch module (K0108) and electric connection between controllers 
(E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit (99214) on May 6, 2020.

You asked the Plan to waive the copayment for a specialist telehealth visit. You say that you understood telehealth appointments to be covered by the Plan with no copayments because of the COVID-19 pandemic. 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 $20 copayment for each specialist visit for Medicare-covered services. 

You have been asked to pay a $20 copayment for a specialist telehealth visit. A specialist telehealth 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 a specialist telehealth visit (99214) on May 6, 2020. 

Your complaint about receiving incorrect or incomplete information about your cost-sharing responsibilities from a representative of the Plan 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on July 21, 2020.

You asked the Plan to waive the copayment for a breast ultrasound. You say that you feel that you should not owe a copayment for a breast ultrasound because you have a history of breast cancer. 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 $100 copayment for ultrasounds. 

You have been asked to pay the allowed amount of $93.54, which is less than the $100 copayment for a breast ultrasound. A breast ultrasound 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 a breast ultrasound provided on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-manipulative chiropractic services provided on May 29, 2019 and June 5, 2019.

You asked the Plan to pay for the non-manipulative chiropractic services (97012, 97039, G8730, G8942). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the non-manipulative services from a chiropractor do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-manipulative chiropractic services (97012, 97039, G8730, G8942) have not been met. Therefore, we decided that the Plan does not have to pay for the non-manipulative chiropractic services provided on May 29, 2019 and June 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cialis 5mg tablets.

You asked the Plan to pre-approve Cialis. You say that Cialis is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.

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 Cialis 5mg tablets. 

Benefits for Cialis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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. The Plan denied your request. The Plan says the services can be provided at a lower 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 acute care hospital with sepsis secondary to lower extremity wounds. Broad spectrum antibiotics have been administered. A lower extremity angiogram was performed and not further intervention was needed, as there was sufficient blood flow. LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a history 
of Parkinson's disease, dementia, and diverticulosis, who was admitted to the acute care hospital on 10/25/20 
with gastrointestinal bleeding. No source for the bleeding was found, and the enrollee was observed. The 
enrollee was found to have pneumonia. A PEG tube has been placed, as there was concern for aspiration. 
 
The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation 
needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  It is not 
clear that the enrollee in this case would be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy of veins in the left leg. 
 
You asked the Plan to pre-approve the sclerotherapy of veins in the left leg. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
member has not tried 3 months of conservative therapy. 
 
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 the sclerotherapy of veins in the left 
leg. Our reviewer says that the requested items/services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found the documentation does not support that the enrollee's venous 
 insufficiency has been refractory to a 3 month trial of conservative therapy and graduated compression 
stockings. 
 
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 sclerotherapy of veins in the left leg have not been met. Therefore, we 
decided that the Plan does not have to pre-approve sclerotherapy of veins in the left leg.