Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation provided on April 28, 2020. 
 
You asked the Plan to pay for the limited oral evaluation. You say that after a long wait you were advised that 
they don't accept your plan. You say that you should be able to see another provider. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
limited oral evaluation provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided 
from January 12, 2020 to February 4, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not be 
responsible for a second copayment. The Plan denied your request. The Plan says that 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 $289 
copayment for per day, days 1 to 6 of Inpatient hospital care.  
 
You have been asked to pay a $1,734 copayment for the inpatient hospital services from January 12, 2020 
through February, 2020. The inpatient hospital services fall within the days 1 to 6 of 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 the inpatient hospital services 
provided from January 12, 2020 to February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided to the enrollee on 
November 13, 2019. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says the provider has not supplied the requested medical documentation needed to complete 
processing. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have metastatic bladder cancer.  Testing specifically related to bladder cancer, for 
which associated therapies are known, is medically necessary and reasonable.  Panel testing, inclusive of 
testing that is not related to bladder cancer or for which there are no associated therapies, is not medically 
necessary or reasonable.  The documentation does not support that the performed panel testing was medically 
necessary or reasonable. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Guardant360 testing provided to the enrollee on November 13, 2019.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
minimal/standby assist for functional transfers and activities of daily living (ADL's) and a less intensive, 
longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted 
period. An IRF intensity is not 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 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on April 6, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without 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 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 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 the laboratory services rendered by the out of network (OON) provider on April 6, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit (99350) provided on July 12, 2019. 
 
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your 
request. The Plan says this service was performed by a CNA rather than a 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.  A home visit cannot be billed by a physician 
unless the physician was actually present in the beneficiary's home. 
 
We find that CPT code 99350 is not supported in the medical record.  Specifically, the records do not support 
that the billing physician was present in the enrollees home. The records indicate that the visit in question was 
a skilled nursing visit performed by a certified nursing assistant. Based on this information, we decided that 
Medicare rules for coverage of a home visit have not been met. Therefore, we decided that the Plan does not 
have to pay for a home visit (99350) provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan provided on February 24, 2020. 
 
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says non-emergent, 
non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
duplex scan. 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 duplex scan provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99214)  provided on February 24, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you extended treatment in good faith 
based on the expectation of payment. Therefore, you are requesting a thorough review of the claim to be 
reprocessed and expedite payment. The Plan denied your request. The Plan says enrollees must receive their 
medical services from an in-network provider. The plan says that non-emergent services with non-contracted 
providers require prior-authorization prior to services being rendered. 
 
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 outpatient office visit (99214)  provided on 
February 24, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320) and consultation (D9310) 
provided on April 10, 2020. 
 
You asked the Plan to pay for endodontic therapy (D3320) and consultation (D9310). You say that you had a 
bad toothache and your dentist office was closed. You say that this should be covered because you were 
referred by an in-network dentist. The Plan denied your request. The Plan says the services are not covered 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
endodontic therapy (D3320) and consultation (D9310) provided on April 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Aminolevulinic acid (J7345) provided on February 24, 2020. 
 
You asked the Plan to pay for the Aminolevulinic acid. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not 
support the number of units billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code J7345 is Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg. 
 
We asked our coder 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 Aminolevulinic acid. Our reviewer says that CPT code 
J7345 meet criteria for billing and reimbursement consideration. Our reviewer found the documentation in the 
office visits states "The contents of an Ameluz tube were applied to the face and ear and incubated for 
01:00:00.  The documentation supports the units billed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Aminolevulinic acid have been met. Therefore, we decided that the Plan has 
to pay for Aminolevulinic acid (J7345) provided on February 24, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 20mg tablet (J7512). 
 
You asked the Plan to pre-approve Prednisone 20mg tablet. You say that the medication is necessary. The Plan 
denied your request. The Plan says the enrollee has a medical only policy which does not include Part D 
prescription coverage, therefore the criteria for self-administered drug coverage has not been met. 
 
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 Prednisone 20mg tablet 
(J7512).  
 
Benefits for Prednisone 20mg tablet 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on 
November 9, 2019. 
 
You asked the Plan to pay for the incision and drainage of an abscess. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more 
appropriate code that should be billed for this 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, the CPT Code Manual definition of code 10061 is incision and drainage of abscess (eg, carbuncle, 
suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or 
multiple. 
 
We asked our coder 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 incision and drainage of an abscess. Our reviewer says 
that CPT code 10061 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
emergency room visit report describes a simple incision and drainage. There is a more appropriate code for this 
procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the incision and drainage of an abscess have not been met. Therefore, we 
decided that the Plan does not have to pay for the incision and drainage of an abscess (10061) provided on 
November 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you are not able to 
take part in 3 hours of therapy a day. 
 
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 physician reviewer found 
that you are generally medically stable with no recent neurological or orthopedic events. There is no evidence 
of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or a 
need for acute rehab nursing care. While you may benefit from continuing physical and occupational therapy, 
there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent 
physician oversight and an interdisciplinary approach to rehabilitation care. You are not expected to make the 
progress anticipated in the predicted period of time. Admission to an IRF is not medically necessary based on 
lack of medical complexity and current functional status. 
 
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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly 
moderate to maximum assist for functional transfers and activities of daily living (ADLs) and a less intensive, 
longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted 
period. An IRF intensity is not 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 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: 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues 
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other 
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is 
mostly moderate to maximum assist for functional transfers and activities of daily living (ADL's) and a less 
intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully 
benefit and/or participate in an IRF level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a knee orthosis (L1832). 
 
You asked the Plan to preapprove the orthoses. You say that you have knee pain. The Plan denied your request. 
The Plan says you do not meet Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses can be approved if you have 
documented knee instability and objective description of joint laxity. The item may be approved if you have 
had a recent injury or a surgical procedure on the knee.  
 
The documentation does not show you have any of the covered indications. Therefore, we decided that the Plan 
does not have to preapprove a knee orthosis (L1832).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office services provided from 
February 27, 2020 through March 19, 2020. 
 
You asked the Plan to waive the copayment for the specialist office services. You say that you are appealing 
your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the 
claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the specialist office services provided from February 27, 2020 
through March 19, 2020. You were seen for three dates of service and are asked to pay a $35 copayment for 
each date of service for specialist office services. Your EOC states that enrollees must pay a $35 copayment for 
specialist office visits. 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 specialist office services 
provided from February 27, 2020 through March 19, 2020.