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

 
We decided that the Plan does not have to pay for physician's services provided on June 8, 2020. 
 
You asked the Plan to pay for the physician's services. 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 
physician's services. 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 physician's services provided on June 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the right shoulder (73030) provided on June 22, 
2020. 
 
You asked the Plan to pay for an x-ray of the right shoulder. You say that this is supported by the records. The 
Plan denied your request. The Plan says this was billed with an incorrect diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the billing of this claim is not supported. Specifically, this service was billed with modifier RT, 
which indicates that it was performed on the right side, but the billed diagnosis, S42.202D, is a fracture of the 
left humerus. Based on this information, we decided that Medicare rules for coverage of an x-ray of the right 
shoulder have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the right 
shoulder (73030) provided on June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator (E1390). 
 
You asked the Plan to pre-approve oxygen concentrator. You say that the concentrator should be covered 
because tanks are difficult to use. The Plan denied your request. The Plan says only rented oxygen equipment 
can be eligible for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover purchased oxygen 
equipment.  
 
We looked at the file and Medicare rules. Oxygen equipment cannot be covered when purchased. Based on this 
information, we decided that Medicare rules for coverage of oxygen concentrator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an oxygen concentrator (E1390).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip and an inpatient mental 
health services provided by participating providers on February 5, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip and inpatient mental health services. You say 
that you are dissatisfied with the services that were provided. The Plan denied your request. The Plan says the 
correct copayments have 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 $275 
copayment for ambulance services/in-network/ground and a $350 copayment per day for days 1-5. There is a 
$0 copayment for additional days for inpatient mental health care/in-network.  
 
You have been asked to pay a $275 copayment for an ambulance trip and a $350 copayment per day for one 
day for an inpatient mental health stay. The total amount you are being asked to pay is $625 ($275 + $350 = 
$625). An ambulance trip falls within the ambulance services/in-network/ground benefit category and inpatient 
mental health services fall within the inpatient mental health care/in-network 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 waive the copayment for an ambulance trip and an inpatient mental health services provided by 
participating providers on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 
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 physician's services provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that 
the enrollee needs an abutment and crown in order to complete the implant procedure. The Plan denied your 
request. The Plan says these services are not covered under the enrollee's benefit package. 
 
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 a 
custom fabricated abutment (D6057) and implant supported crown (D6066).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT). 
 
You asked the Plan to pre-approve proton beam radiation therapy (PBRT). You say that the requested PBRT is 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for proton 
beam radiation therapy (PBRT). 
 
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 proton beam radiation therapy (PBRT). 
Our reviewer says that the enrollee does not meet criteria for proton beam radiation therapy (PBRT). Our 
physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer 
proton beam therapy on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy (PBRT) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found the review 
indicates that the enrollee was hospitalized for symptomatic hyperglycemia and hypercapnic respiratory failure. 
The enrollee is status post several bronchoscopy procedures due to increased mucous plug and aspiration 
pneumonia. She was extubated on 10-28-20 and is tolerating high flow oxygen. Per the reviewed 
documentation: 10/29/20 Hospitalist note on high flow oxygen, moderate respiratory distress O2 saturations 
91-94%. Receiving tube feeds. 
 
There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate 
care at the current acute care facility. The review has determined that the enrollee does not require services at 
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 11, 
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 the records do not support the services 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 the denied codes is: 
 
CPT 80157: 
 
Carbamazepine; free testing 
 
CPT 80159: 
 
Clozapine testing with a serum specimen 
 
CPT 80162: 
 
Digoxin; total testing 
 
CPT 80173: 
 
Haloperidol testing with a serum specimen 
 
CPT 80177: 
 
Levetiracetam testing with a serum specimen 
 
 
 
CPT 80201: 
 
Topiramate testing with a serum specimen 
 
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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
specimen collection types for the code and records do not match. Blood specimen collection is by 
venipuncture, however, the lab requisition states a urine specimen was collected; therefore, the billed service 
cannot be verified. 
 
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 pay for drug testing services provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 30, 2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
there is no valid referral for this service. 
 
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 
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 a domiciliary, rest home visit provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab work provided by a participating 
hospital on June 23, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you had this don't with your provider. 
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 $50 
copayment for outpatient diagnostic tests/in-network/lab/outpatient hospital.  
 
You have been asked to pay a $50 copayment for lab work. Providers can be contracted by hospital; therefore, 
resulting in an outpatient hospital copayment. Lab work falls within the outpatient diagnostic tests/in-
network/lab/outpatient hospital 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 
lab work provided by a participating hospital on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmology visits you had on June 
24, 2020, and July 29, 2020. 
 
You asked the Plan to waive the copayments for the ophthalmology visits. You say that you just went in for a 
routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you were 
charged these copayments 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 $35 
copayment for Medicare-covered eye exams too diagnose and treat diseases and conditions of the eye.  
 
You have been asked to pay a $35 copayment for the ophthalmology visits. We looked at the medical records 
from these two dates of service.  Based on these records, you were seen on June 24, 2020, for a follow-up visit 
related to macular degeneration.  The records confirm that this was not a routine eye exam, but rather a medical 
exam to evaluate this condition.  That is why the copayment applied.  In addition, we looked at the medical 
records for the July 29, 2020, date of service.  The medical records from that visit clearly indicate that you were 
seen for complications from glaucoma. This was not a routine eye exam, so a copayment appropriately applied 
to this visit as well. 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 the ophthalmology visits you 
had on June 24, 2020, and July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional speech therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan has approved 12 visits prior, plus five additional visits to finalize a home 
program. 
 
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 the 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 requested additional therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition, and it 
does not appear that the enrollee requires  the unique skills of a professional therapist to safely and effectively 
provide treatment, that the services can be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The enrollee is on a regular diet. The enrollee has been authorized additional 
sessions to review an independent exercise program and ensure safety.  
 
The ongoing specialized skill, knowledge and judgment of a qualified therapist is not required to establish, 
design and/or deliver a program to maintain the enrollee's condition, or to prevent or slow further deterioration. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve additional speech therapy visits for the enrollee.
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. You say that the enrollee would benefit from a 3 hours per day intensive rehab program to maximize functional independence for a safe discharge home. The Plan denied your request. The Plan says an admission to an IRF is not medically necessary at this time.

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 there is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. Our reviewer found that the documentation does not support that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. Our physician reviewer also found that the enrollee's rehab needs can be met in an alternate, less intense setting.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services you received from 
January 7, 2020, to July 31, 2020. 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you just found out that you 
were charged coinsurance instead of your normal copayment. The Plan denied your request. The Plan says you 
were charged this coinsurance correctly. The Plan says that your cost sharing changed between 2019 and 2020. 
 
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 20% 
coinsurance for dialysis services in 2020.  
 
You have been asked to pay 20% coinsurance for the dialysis services. 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 dialysis services you received from January 7, 2020, to July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular embolization/occlude organ, prostate artery 
embolization. 
 
You asked the Plan to pre-approve vascular embolization/occlude organ, prostate artery embolization. You say 
that the requested vascular embolization/occlude organ, prostate artery embolization is medically necessary. 
The Plan denied your request. The Plan says the requested vascular embolization/occlude organ, prostate artery 
embolization is not medically necessary. 
 
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 vascular embolization/occlude organ, 
prostate artery embolization. Our reviewer says that the requested vascular embolization/occlude organ, 
prostate artery embolization is not medically necessary. Our physician reviewer found the enrollee is with BPH 
and lower urinary tract symptoms. Treatment with tamsulosin is no longer effective and symptoms have 
recurred. Request is for coverage of prostate artery embolization.  
 
Prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH. Very limited 
international studies have demonstrated possible short-term safety and efficacy. Comparative studies to other 
methods such as TURP are pending. The requested procedure is not medically necessary 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 vascular embolization/occlude organ, prostate artery embolization have not 
been met. Therefore, we decided that the Plan does not have to pre-approve vascular embolization/occlude 
organ, prostate artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an influenza vaccine provided on October 8, 2019. 
 
You asked the Plan to pay for the influenza vaccine. 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 
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 an influenza vaccine provided on October 8, 2019.