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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on February 10, 2020, to February 15, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were dissatisfied 
with the services that were provided. 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 $300 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $300 copayment per day for days 1-5 for an inpatient hospital stay. The total 
amount you are being asked to pay is $1,500 ($500 x 5 days = $1,500). An inpatient hospital stay falls within 
the inpatient hospital 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 inpatient 
hospital stay provided by a participating provider on February 10, 2020, to February 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on August 4, 
2020. 
 
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 services rendered by non-participating 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 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 medical services provided to the enrollee on 
August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray interpretation provided on June 25, 2020. 
 
You asked the Plan to pay for the chest x-ray interpretation (71045-26). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the code is inclusive to service code 32555 which was 
billed by and paid to the same provider on for the same date of service. 
 
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, we have confirmed that code 71045 
has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the chest x-ray interpretation (71045-26) provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311). 
 
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan 
denied your request. The Plan says there is not a need to control the power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically 
necessary for the above functions. 
 
 
 
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 an expandable controller. Our reviewer 
says that the requested items are not medically necessary. Our physician reviewer found the documentation 
does not reveal that the patient requires other types of proportional input devices or non-proportional input 
devices. The patient does not need to operate 3 or more powered seating actuators through the drive control, a 
separate display, other electronic devices, or an attendant control. The patient's upper extremity strength and 
function are sufficient for the patient to control any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2313, E2311).
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for an ambulance transport provided May 16, 2020. 
 
You asked the Plan to pay for the ambulance transport. You say that the transport was medically necessary. 
The Plan denied your request. The Plan says that the service was billed with the GY modifier as the transport 
was not medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patient?s health. The Plan follows the same rules.  
 
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 ambulance transport. Our reviewer says 
that the ambulance transport was medically necessary. Our physician reviewer found given the advanced age of 
the patient and the broad differential that these vague symptoms could represent, ambulance transportation was 
warranted. 
 
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 ambulance transport have been met. Therefore, we decided that the Plan has 
to pay for an ambulance transport provided May 16, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the diagnostic mammography provided on 
March 6, 2020. 
 
You asked the Plan to waive the cost share for the diagnostic mammography. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a diagnostic mammography on the date of service at issue in 
this appeal. The Plan says the correct cost share has applied per your contract with the Plan. 
 
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 says that there is a $150 deductible that 
must be met before the Plan will pay their share for Outpatient diagnostic tests. Your contract with the Plan 
also clearly says that you must pay a 5% coinsurance for Outpatient diagnostic tests once the deductible is met.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic 
mammography on March 6, 2020.  
 
 
 
 
 
This service you asked the Plan to waive the cost share for falls within the Outpatient diagnostic tests benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 
deductible that must be met before the Plan will pay their share for Outpatient diagnostic tests. This cost 
sharing is a contractual obligation that had not been met until you received your diagnostic mammography on 
March 6, 2020. As you met your $150 deductible, your Outpatient diagnostic test coinsurance applied as well, 
leaving you responsible for a total amount of $51.27. 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 cost share for the 
diagnostic mammography provided on March 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper and lower dentures. 
 
You asked the Plan to pre-approve the dentures. You say that you feel that these dentures should be replaced 
since they were lost when housekeeping threw them away. The Plan denied your request. The Plan says your 
dental benefit does not cover dentures. 
 
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 pre-approve 
upper and lower dentures.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that they do not see that the enrollee needs more skilled therapy that cannot 
be done at another level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided by a 
participating provider on May 12, 2020. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you do not agree with this 
copayment. 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 $40 
copayment for outpatient diagnostic tests/in-network/radiation therapy.  
 
You have been asked to pay a $40 copayment for radiation therapy. The correct copayment has been applied to 
the services provided. Radiation therapy falls within the outpatient diagnostic tests/in-network/radiation 
therapy 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 radiation therapy provided 
by a participating provider on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for traction, therapy and x-rays provided from May 13, 2020, to 
June 8, 2020. 
 
You asked the Plan to pay for chiropractic services other than manual manipulation of the spine to correct 
subluxation. You say that the Plan told the provider all the services would be covered. The Plan denied your 
request. The Plan says only spinal chiropractic manipulative treatment is covered. 
 
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.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for traction, therapy and x-rays provided from May 13, 2020, to June 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation. 
 
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation 
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
requested radiofrequency ablation. 
 
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 radiofrequency ablation. Our reviewer 
says that the enrollee does not meet criteria for the requested radiofrequency ablation. Our physician reviewer 
found the enrollee has chronic neck and low back pain. He is taking oxycodone for pain. He is status post multi 
level anterior cervical fusion and also has a Herniated cervical disc. He had one set of diagnostic medial branch 
blocks and achieved 30-40% pain relief. 
 
The criteria for diagnosis of facet mediated pain generator is 80% pain relief from dual diagnostic blocks.  This 
can be achieved with local anesthetic alone and does NOT require steroids.  This was not done and the single 
set of diagnostic blocks produced only 30-40% pain relief.  Therefore, the test was NEGATIVE and the 
requested procedures are 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the EMS. on September 9, 2019. 
 
You asked the Plan to pay for the ambulance services. You say that you were unable to ride in a vehicle due to 
extensive injuries. 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 pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor?s office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor?s office. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by the EMS on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit received on June 26, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services received are not a covered benefit. 
 
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.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit received on June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you need more time to get stronger and more 
therapy. The Plan denied your request. The Plan says that the services you require are considered custodial 
care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GeneSight genetic testing provided on May 11, 2020. 
 
You asked the Plan to pay for the GeneSight genetic testing. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that GeneSight genetic testing is only covered for certain 
indications. 
 
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 GeneSight genetic testing. Our reviewer 
says that the documentation does not support that the GeneSight genetic testing rendered was medically 
reasonable or necessary. Our physician reviewer found the enrollee has diagnoses of Generalized anxiety 
 
 
disorder and Major depressive disorder, recurrent, unspecified. The documentation does not contain clinical 
records documenting that this enrollee is suffering with refractory moderate to severe depression (based upon 
DSM-V criteria) after at least one prior neuropsychiatric medication failure, and that a licensed psychiatrist or 
neuropsychiatrist is contemplating an alteration in neuropsychiatric medication. Therefore, the enrollee did not 
meet criteria for the services rendered. 
 
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 GeneSight genetic testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the GeneSight genetic testing provided on May 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 24, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
states a urine specimen was collected. 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 provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on April 
21, 2020. 
 
You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that you feel you should not 
be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received a Euflexxa injection on the date of service at issue in this 
appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan. 
 
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 Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Euflexxa 
injection on April 21, 2020. You have been asked to pay a 20% coinsurance for the Euflexxa injection, totaling 
$408.73. The Euflexxa injection falls within the Medicare Part B prescription 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 Euflexxa injection provided on April 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renacidin Solution for the enrollee. 
 
You asked the Plan to pre-approve Renacidin Solution. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Renacidin Solution for the enrollee.  
 
Benefits for Renacidin Solution may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.