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

We decided that the Plan does not have to waive the copayment for programming device evaluation (in person) 
with iterative adjustment of the implantable device to test the function of the device and select optimal 
permanent programmed values with analysis, review and report by a physician or other qualified health care 
professional (93280) Interrogation device evaluation(s) (remote), up to 90 days (93295) provided May 11, 2020 
to July 17, 2020. 
 
You asked the Plan to waive the copayment for cardiac device monitoring services. You say that you are 
confused why you are required to pay copayments. The services are special physician services. Therefore you 
do not believe you are responsible for the payment. The Plan denied your request. The Plan says the claims 
were processed with the correct copayment applied per the plan's Evidence of Coverage. 
 
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 $10 
copayment for Medicare covered non-radiological diagnostic services for Outpatient diagnostic tests and 
therapeutic services and supplies.  
 
You have been asked to pay $20 ($10 + $10 = $20) for the cardiac device monitoring services. Per the letter 
you provided, the waiver does not include diagnostic tests and certain other services. The cardiac device 
monitoring services 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 programming device evaluation (in person) 
with iterative adjustment of the implantable device to test the function of the device and select optimal 
permanent programmed values with analysis, review and report by a physician or other qualified health care 
professional (93280) Interrogation device evaluation(s) (remote), up to 90 days (93295) provided May 11, 2020 
to July 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on July 
13, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you were told the visit 
would be covered. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
emergency room visit provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to require additional short term acute care services which can be 
safely received in the current setting. The patient does not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer may be considered when the patient's treatment is 
completed. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no face to face examination. 
 
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.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not reveal that your mobility deficit impairs participation in MRADLs in the home. The documentation 
does not reveal why thedeficit cannot be helped by a walker or manual wheelchair. There is no objective 
detailed  neuromuscular exam. The documentation is not clear that you would be able to safely maneuver the 
power scooter in your home. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xifaxan. 
 
You asked the Plan to pre-approve Xifaxan. 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 Xifaxan.  
 
Benefits for Xifaxan 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 3, 
2020, through June 1, 2020. 
 
You asked the Plan to pay for the SNF care. You say that the services which the enrollee required and received 
are coverable under the Medicare Act. The Plan denied your request. The Plan says the services received 
during this time frame are considered custodial, as this is care provided in a facility setting when the enrollee 
did not need skilled medical care or skilled nursing 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 pay for the SNF care. Our reviewer says that the 
skilled nursing facility care provided was not medically necessary.  
 
 
 
Our physician reviewer found that according to the medical records provided, the patient did not require skilled 
nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, the patient did not 
require the services on an inpatient basis, in a skilled nursing facility setting. The services provided were 
custodial in nature.  
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for the skilled nursing facility (SNF) care provided from May 3, 2020, through June 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the thorax (71250). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this service is not medically necessary. 
 
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 CT Scan. Our reviewer says that the 
lesions in question have been stable and repeat imaging study not indicated. Our physician reviewer found the 
requested CT Scan is not 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 the CT Scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CT Scan of the thorax (71250).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-obstetrical transvaginal ultrasound 
(76830) non-obstetrical transabdominal ultrasound, real time with image documentation; complete (76856) 
provided on July 6, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic services. You say that the ultrasound was done 
on the same date and time and indicates a copay for each coded procedure. You do not feel you should have to 
pay 2 copays. The Plan denied your request. The Plan says the claim processed with the correct copayment 
applied per the plan 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). Your contract with the Plan clearly says that you must pay $110 
copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a 
physician?s office or at a free-standing facility.  
 
You have been asked to pay $209.12 ($104.56 + $104.56) copayment for the diagnostic services. The allowed 
amount was lower than the copayment amount so you were held liable for the allowed amounts. The diagnostic 
services fall 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 non-obstetrical transvaginal 
ultrasound (76830) non-obstetrical transabdominal ultrasound, real time with image documentation; complete 
(76856) provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 28. 
 
You asked the Plan to pre-approve the core build up. You say that the requested services are medically 
necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
build up (D2950) for tooth # 28.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 19, 
2020, to May 20, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found that the record does not show that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from May 19, 2020, to May 20, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the robotic surgical techniques (S2900) provided on 
February 26, 2020. 
 
You asked the Plan to pay for the robotic surgical techniques. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says CPT code S2900 has a status 
indicator of I which is not valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S2900 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S2900 has a status indicator of I. This means that CPT code S2900 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the robotic surgical techniques have 
not been met. Therefore, we decided that the Plan does not have to pay for the robotic surgical techniques 
(S2900) provided on February 26, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve brain imaging, positron emission tomography (PET); metabolic 
evaluation (CPT Code 78608). 
 
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your 
request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our 
physician reviewer found given early symptoms, living alone status, driving status, driving issues, and 
nutritional issues feel there is reasonable cause that patient may have early onset dementia and feel the PET is 
integral in the diagnosis so that a plan can be initiated for management medically and socially. 
 
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 PET scan have been met. Therefore, we decided that the Plan has to pre-
approve brain imaging, positron emission tomography (PET); metabolic evaluation (CPT Code 78608).  
 
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 lift chair provided on May 5, 2020. 
 
You asked the Plan to pay for the lift chair. You say that you would like reconsideration because you were told 
this equipment would be reimbursed at a higher amount. The Plan denied your request. The Plan says your 
request for additional payment is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lift chair have not been met. Specifically, the record indicates that the Plan reimbursed you for 
the lift chair. Therefore, we decided that the Plan does not have to pay for the lift chair provided on May 5, 
2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that the ambulance staff did not think they 
should transport you due to COVID-19. 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 does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 10, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the 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 he 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. Consequently, 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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CarcioMEMS HF System and associated procedures 
(CPT Codes: C2624 and 33289). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says medical studies haven't proven that the use of the product(s) is helpful for treatment of 
the member's health problem. 
 
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 services. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this circumstance; therapy change based on data obtained from a 
CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital 
readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias 
in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met, since the device should still be considered experimental or 
investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, 
we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CarcioMEMS HF System and associated procedures (CPT Codes: C2624 
and 33289).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray (71045) provided on June 15, 2020. 
 
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says preventive services are not an emergency medical 
condition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
We find that CPT code 71045 is not supported in the record. Specifically, the place of service code billed, POS 
23, does not support the preventive diagnosis code billed. It is unclear why the provider is billing a preventive 
diagnosis code when the services were rendered in the emergency department.  Based on this information, we 
decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the 
Plan does not have to pay for the chest x-ray (71045) provided on June 15, 2020.