Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional physical therapy visits.You asked the Plan to pre-approveadditional physical therapy visits. You say that the enrollee still has pain and restricted range of motion. You say that therapy needs to continueto improve balance for fall prevention.The Plan denied your request. The Plan says additional visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy for this condition and has been compliant in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient care provided from June 2, 2020, to June 8, 2020. 
 
You asked the Plan to pay for inpatient care. You say that the allowed amount for these services is not $0. The 
Plan denied your request. The Plan says that the allowed amount for these services is $0. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not provided a citation to explain why the allowed amount for 
these services is zero. Though the Plan references multiple claim elements, there is no clear issue with these 
claim elements and there is no explanation as to why the claim is not payable as billed. Therefore, we decided 
that the Plan has to pay for inpatient care provided from June 2, 2020, to June 8, 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: 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 this is for medical necessity. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepatha Sureclick.You asked the Plan to pre-approveRepatha. You say that the enrollee is unable to tolerate statins.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally doesnot 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-approveRepatha Sureclick.Benefits for Repathamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an adjustable knee orthosis provided by a 
participating provider. 
 
You asked the Plan to waive the coinsurance for an adjustable knee orthosis. You say that you do not agree 
with this. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for prosthetic devices and related supplies.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an adjustable knee orthosis. The 
total allowed amount is $658.83. The total amount you are being asked to pay is $131.77 ($658.83 x 20% = 
$131.77). An adjustable knee orthosis falls within the prosthetic devices 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 an adjustable knee orthosis provided by a participating 
provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET/CT scan. 
 
You asked the Plan to pre-approve a PET/CT scan. You say that the requested PET/CT scan is medically 
necessary. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 a PET/CT scan. Our reviewer says that 
the requested PET/CT scan is medically necessary. Our physician reviewer found the enrollee is with a hyper-
inflammatory syndrome of some kind, resulting in weight loss, malaise, and general poor health. The source of 
the inflammation is unclear. The enrollee's rheumatologist would like to get a PET/CT scan to help identify the 
part of the body where the bulk of the inflammation is coming from, to provide a more definitive diagnosis, 
allowing for more targeted and appropriate therapy. 
 
Non-covered indications include chronic osteomyelitis, infection of hip arthroplasty, and fever of unknown 
origin. The enrollee in this case does not have a Nationally Non-Covered Indication for a PET/CT scan. There 
are many established non-oncologic indications for PET/CT. The requested PET/CT scan is medically 
reasonable and necessary in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET/CT scan.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Tempus xT genetic panel rendered on May 1, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says that the services were medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that NGS panels are covered when specific criteria 
are met. 
 
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 these services. Our reviewer says that the 
services were medically necessary. Our physician reviewer found the enrollee is diagnosed with high-grade 
invasive and metastatic urothelial carcinoma. The documentation supports that the enrollee in this case has 
advanced stage III or IV cancer, and has decided to seek further cancer treatment. There is no indication that 
the enrollee has been previously tested using the same NGS test for the same primary diagnosis of cancer. The 
testing was 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the Tempus xT genetic panel rendered on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on August 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 (99214) provided on August 5, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
July 10, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you should only be charged an 
emergency room (ER) copayment because you were not admitted. The Plan denied your request. The Plan says 
the copayment was 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). Your contract with the Plan clearly says that you must pay a $300 
copayment for outpatient observation services.  
 
Review of the file shows that you received outpatient observation services on July 10, 2020. The records 
confirm that you were placed under observation status. You have been asked to pay a $300 copayment for these 
services. These services fall within the outpatient observation 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 waive the copayment for the outpatient hospital services rendered on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient services provided on March 
11, 2020 and March 12, 2020. 
 
You asked the Plan to waive the copayment for the outpatient services. You say that you should not have a 
copayment. The Plan denied your request. The Plan says you were charged the copayment correctly and the 
original bill you received was before insurance payment. 
 
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 $275 
copayment for Outpatient Surgery.  
 
You have been asked to pay a $275 copayment for the outpatient services. The outpatient services fall within 
the Outpatient Surgery 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 
outpatient services provided on March 11, 2020 and March 12, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit (99215) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee has seen multiple in-network 
providers without success. The Plan denied your request. The Plan says there are additional in-network options 
available to treat the enrollee's medical condition. 
 
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 
the office visit (99215) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitor supplies provided. 
 
You asked the Plan to pay for therapeutic continuous glucose monitor supplies. 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. Medicare rules say that CGM and supplies are only covered for certain 
indications. 
 
We looked at the file and Medicare rules. Review of the file does not support that the enrollee performs 
frequent (four or more times a day) testing. Based on this information, we decided that Medicare rules for 
coverage of therapeutic continuous glucose monitor supplies have not been met. Therefore, we decided that the 
Plan does not have to pay for therapeutic continuous glucose monitor supplies provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 18, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. In addition, you were referred to the 
laboratory by an OON provider. 
 
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 laboratory services provided on November 18, 
2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a bridge for teeth # 9, 10 and 11. 
 
You asked the Plan to pre-approve the dental item. You say that you are suffering. You say that you have lost 
15 pounds in the last 3 months. You also say that you are becoming depressed. The Plan denied your request. 
The Plan says that you do not have sufficient benefits remaining to cover the requested procedure. The Plan 
says tooth # 10 can be replaced by a lesser means. The Plan also says the bridge is not medically necessary to 
restore masticatory function. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
item when the services are medically necessary and reasonable. 
 
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 dental item. Our reviewer says that 
the requested bridge meets the criteria for coverage. Our physician reviewer found coverage for a fixed bridge 
is for replacing a single anterior tooth. In this case tooth #10, an anterior tooth, is to be replaced. Therefore, the 
reviewer found that the requested bridge meets the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental item have been met. Therefore, we decided that the Plan has to pre-
approve a bridge for teeth # 9, 10 and 11.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion/specialty drug administration services 
coded 99601 and 99602 provided on June 18, 2019, and June 19, 2019. 
 
You asked the Plan to pay for the home infusion/specialty drug administration services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not payable. 
 
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 99601 and 99602 are not supported in the medical record. Specifically, these codes 
have a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare 
uses another code for reporting of, and payment of these services. Based on this information, we decided that 
Medicare rules for coverage of the home infusion/specialty drug administration services have not been met. 
Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration 
services coded 99601 and 99602 provided on June 18, 2019, and June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an office visit, an electrocardiogram and 
laboratory services provided on June 15, 2020. 
 
You asked the Plan to waive the copayments for an office visit, an electrocardiogram and laboratory services. 
You say that this was your annual wellness visit and you disagree with the charges. 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 $10 
copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay a 
$20 copayment for diagnostic procedures and tests and laboratory services. 
 
You had an annual wellness visit on June 15, 2020. The diagnostic codes submitted with the claim show that 
services went beyond an annual wellness visit. Therefore, you are responsible to pay a $10 copayment for an 
office visit.  
 
You received an electrocardiogram on June 15, 2020. Therefore, you are responsible to pay the allowed amount 
of $16.42, which is less than the $20 copayment.  
 
You received laboratory services on June 15, 2020. Therefore, you are responsible to pay the total allowed 
amount of $15.17, which is less than the $20 copayment.  
The total amount you owe is: $41.59.  
 
 
 
You have been asked to pay the total amount of $41.59 for an office visit, an electrocardiogram and laboratory 
services. An office visit falls within the physician/practitioner services, including doctor's office visits benefit 
category. An electrocardiogram and laboratory 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 copayments for 
an office visit, an electrocardiogram and laboratory services provided on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve INBRIJA for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 INBRIJA for the enrollee.