Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 15, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says you 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 requested 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 out of network physician services provided on June 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient psychiatric services rendered from June 22, 2019 to July 
2, 2018. 
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that you disagree with the denial. 
The Plan denied your request. The Plan says that the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. Our 
reviewer says that the services were medically necessary. Our physician reviewer found the submitted records 
show that you were admitted to the hospital with Bipolar disorder and unspecified dementia. You were 
showing dangerousness to others, including your son-in-law, and were showing threatening behavior. The 
records support that the services were reasonably expected to improve your condition and for the purpose of 
diagnosis. The inpatient psychiatric services were 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 inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pay for the inpatient psychiatric services rendered from June 22, 2019 to July 2, 2018.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on April 28, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services provided 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 L1906, L0650, L3170, and L1833 are not supported in the medical record. 
Specifically, the medical records lack in-person assessment information such as range of motion, strength tests, 
or claims history with this prescriber. Based on this information, we decided that Medicare rules for coverage 
of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses 
provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Marfan Syndrome and Related Aortopathies 
Sequencing Panel. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing (NGS) is covered 
when specific criteria are met. 
 
We looked at the file and Medicare rules. The NGS panel is being requested for splenic artery aneurysm, rectal 
prolapse, and joint hypermobility. These are not conditions for which Medicare covers NGS panels. Therefore, 
we decided that the Plan does not have to pre-approve a Marfan Syndrome and Related Aortopathies 
Sequencing Panel.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, prophylaxis, and periodic oral evaluation 
provided on July 27, 2020, by an OON provider. 
 
You asked the Plan to pay for the bitewings, prophylaxis, and periodic oral evaluation. You say that you were 
advised that all cleanings were completely covered, even when they were provided OON. The Plan denied your 
request. The Plan says the total liability amount of $164.00 was applied correctly. The Plan also says that 
enrollee liability is a contractual obligation under the Plan and cannot be waived. 
 
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, you are responsible for the difference 
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for 
the bitewings, prophylaxis, and periodic oral evaluation provided on July 27, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided. 
 
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you used the device 
and woke up in a pool of blood and returned the equipment. 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 15% 
coinsurance for DME and related supplies.  
 
You received DME and related supplies. The total allowed amount is 
$1,887.95 and 15% of that is $283.19. 
 
You have been asked to pay the total coinsurance amount of $283.19 for DME and related supplies. DME and 
related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided on July 17, 2020, 
July 21, 2020 and July 24, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the therapy is prescribed by her 
doctor and is medically necessary. You say that all expenses, including copayments, should be covered. The 
Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $10 copayment for physical therapy from at an in-network specialist's office and comprehensive 
outpatient rehab facility.  
 
The enrollee has been asked to pay a $10 copayment for each physical therapy visit. The total amount owed is 
$30 ($10/visit x 3 visits = $30). Physical therapy falls within the "Outpatient rehabilitation services" benefit 
category. The Plan says that only expenses for primary care visits, outpatient behavioral health visits and 
telehealth visits related to a Covid-19 diagnosis are waived.  
 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for physical therapy provided on July 17, 2020, 
July 21, 2020 and July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin (trastuzumab). 
 
You asked the Plan to pre-approve Herceptin. You say that the enrollee has metastatic MSS, KRAS mutated, 
HER2+ rectal cancer. You also say that the goal of treatment is to palliate disease, disease-related symptoms, 
improve quality of life and hopefully prolong life. The Plan denied your request. The Plan says the requested 
drug is not supported in the National Comprehensive Cancer Network (NCCN) guidelines for your type of 
cancer. The Plan also says there may be other treatment choices that NCCN does recommend for you that have 
shown better data for success in treating your cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Herceptin. Our reviewer says that the 
requested drug is not medically necessary. Our physician reviewer found the requested use of Herceptin is not 
FDA approved. The reviewer found that the use of the drug is not supported in any of the CMS compendia. 
The reviewer found that the use is not listed as not indicated, not supported or not recommended in any of the 
compendia. Therefore, the reviewer found that the requested drug is not medically reasonable or 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 Herceptin have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Herceptin (trastuzumab).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the assistant surgeon services provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says assistant surgeon 
services are not payable for this code. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 
38525. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means 
that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based 
upon this information, we find that Medicare coverage criteria for the services have not been met. Therefore, 
we decided that the Plan does not have to pay for the assistant surgeon services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Life Alert System (A9280). 
 
You asked the Plan to pre-approve a Life Alert System. You say that this is necessary for your safety. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that that Telephone Alert Systems are not covered 
because these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. 
 
We looked at the file and Medicare rules. The requested item is not covered. Based on this information, we 
decided that Medicare rules for coverage of a Life Alert System have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a Life Alert System (A9280).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you had a medical prescription. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen (74170). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan 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 it is expected that the abdominal x-ray is used to 
evaluate patients who present with signs and symptoms suggestive of abdominal pathology prior to proceeding 
to a CT scan. 
 
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 CT scan. Our reviewer says that the 
requested CT scan is not medically necessary at this time. Our physician reviewer found abdominal bloating 
alone is not an indication for a CT of the abdomen. Plain X-ray films or ultrasound would be the standard of 
care for initial study in this 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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) of the abdomen (74170).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home health aide for custodial care. 
 
You asked the Plan to pre-approve a home health aide for custodial care. You say that you need assistance to 
bathe as your arm is immobilized. The Plan denied your request. The Plan says rules for Home Health care 
have not been met. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the custodial care services have not been met. Specifically, this service is not covered by Medicare 
or the Health Plan. Therefore, we decided that the Plan does not have to pre-approve a home health aide for 
custodial care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215, 96127, G0438) and immunization 
(90670) provided on June 24, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an OON office visit and immunization. You say that this should be reprocessed. 
The Plan denied your request. The Plan says this was not authorized. 
 
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 office visit (99215, 96127, G0438) and 
immunization (90670) provided on June 24, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need a power wheelchair to 
participate in daily living chores. The Plan denied your request. The Plan says the records do not show 
evidence that you have problems performing daily activities. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows your condition can be improved by a manual wheelchair. The file does not show that you have a 
mobility deficit that impairs your participation in MRADLs. The Face to Face documentation shows you have 
the upper extremity function to safely propel a manual wheelchair and you do not need a power wheelchair to 
participate in MRADLs at home. This means that Medicare rules for coverage of a PMD have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on June 23, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that the Plan required the MRI so they should 
cover it. 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 $150 
copayment for advanced imaging services provided by a specialist.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI 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 
an MRI provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist/oncologist. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested provider is not a primary provider, and the service requested is available 
within the network. 
 
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 
a referral to an out-of-network hematologist/oncologist.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided from March 21, 
2020, to March 28, 2020. 
 
You asked the Plan to pay for this service. You say that you could not contract a plan provider and this 
physician was within walking distance of your home. The Plan denied your request. The Plan says you 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 out of network physician services provided from March 21, 2020, to March 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transit system for a power wheelchair 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not primarily medical in nature. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a transit kit is used to secure a wheelchair during transportation outside the home.The requested transit 
kit is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transit system for a power wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the podiatry services provided on May 1, 
2020 and June 24, 2020. 
 
You asked the Plan to adjust the coinsurance for the out-of-network podiatry services. You say that you 
thought the provider was in-network and you paid copayments. The Plan denied your request. The Plan says 
you were charged the coinsurance 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 50% 
coinsurance for out-of-network Podiatry Services.  
 
You have been asked to pay 50% coinsurance for the podiatry services. The podiatry services fall within the 
Podiatry 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 adjust the coinsurance for the podiatry 
services provided on May 1, 2020 and June 24, 2020.