Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on June 
22, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not call for an 
ambulance transport, you had a ride waiting. The Plan denied your request. The Plan says you were charged 
this cost sharing 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 $225 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $225 for these 
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 copayment for the ambulance services provided on June 22, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on May 22, 
2020. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan 
says the Plan requires utilization of network providers when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
service 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 psychiatric diagnostic evaluation provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the interrogation device evaluation 
provided on June 8, 2020. 
 
You asked the Plan to reduce the copayment for the interrogation device evaluation (G2066). You say that the 
copayment should be $40 for a specialist visit. 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 $50 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $50 copayment for the interrogation device evaluation (G2066). The 
interrogation device evaluation (G2066) falls within the diagnostic procedures and tests 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 reduce the copayment for the interrogation device evaluation provided on June 8, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caris MI Profile Genetic Testing. 
 
 
You asked the Plan to pre-approve Caris MI Profile Genetic Testing. You say that you would like 
reconsideration because the biomarker results will help to develop the most appropriate treatment plan for the 
member. The Plan denied your request. The Plan says there is insufficient evidence in published medical 
literature that testing all of the 592 genes in the Caris MI Profile test would improve the member's overall 
treatment outcomes. 
 
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 Caris MI Profile Genetic Testing 
. Our reviewer says that the documentation does not support that the number of genes or tests in the Caris MPI 
are reasonable and necessary to obtain necessary information for therapeutic decision making. Our physician 
reviewer found the National Comprehensive Cancer Network does not document that genetic testing improves 
management decision-making. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Caris MI Profile Genetic Testing have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Caris MI Profile Genetic Testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from August 5, 2019, 
to August 7, 2019. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services should be covered. The Plan 
denied your request. The Plan says records were not submitted to support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to 
determine whether payment is due, and the information provided must corroborate the medical records and 
confirm that Medicare coverage criteria have been met. 
 
In this case, the medical records received were not from the admission at issue in this case. These records were 
from an admission from June 20, 2019, to July 22, 2019. Since no records from the August admission were 
submitted, it cannot be confirmed that coverage criteria have been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital services provided from August 5, 2019, to August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth distant site service (G2025) provided on April 
30, 2020. 
 
You asked the Plan to pay for the telehealth distant site service. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the Medicare rules for payment of 
this claim have not been met. 
 
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 G2025 is not supported in the record. Specifically, this claim was not billed with the 
three codes and modifiers required for telehealth distant site services. Based on this information, we decided 
that Medicare rules for coverage of the telehealth distant site service have not been met. Therefore, we decided 
that the Plan does not have to pay for a telehealth distant site service (G2025) provided on April 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. The Plan denied your request. The Plan says this is 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 PT 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 that 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 ongoing 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 has been instructed in an independent exercise 
program. The 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 current 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 additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 21, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that 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 $40 
copayment for each specialist visit.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure, posterior resin-based composite, 
anterior resin-based composite, and extraction provided on July 28, 2020. 
 
You asked the Plan to pay for the preventive procedure, resin-based composites, and extraction. You say that 
there was no reason to take an extra x-ray. The Plan denied your request. The Plan says these services 
processed correctly according to your EOC. 
 
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, you are responsible for a 50% 
coinsurance for each resin-based composite and extraction. The contract also does not list unspecified 
preventive procedure as a covered service. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure, posterior resin-based composite, anterior resin-based composite, and extraction provided 
on July 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically 
necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is 
with lumbar spinal stenosis with neurogenic claudication. The spacer device requested remains experimental. 
More research is needed to show safety and efficacy. The Vertiflex device 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary due to lack of evidence of beneficial outcome. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. There is no 
instability. Hardware is not needed. Open simple laminectomy is the gold standard. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray provided on August 14, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. You say that you have a panoramic x-ray available every 36 
months. You also say that you need the money that you paid for the x-ray. The Plan denied your request. The 
Plan says your panoramic x-ray benefit has been exhausted. 
 
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, panoramic x-rays are limited to one 
every 36 months, unless you have received an intraoral complete series or a panoramic x-ray in a period of less 
than 36 months. The record shows that you received a complete series of intraoral x-rays on June 24, 2020, and 
your panoramic x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for 
the panoramic x-ray provided on August 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 2, 2020, to 
June 3, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that at no time prior to your surgery were 
you advised that there would be additional charges that you would be responsible for. You say that the services 
should be covered. The Plan denied your request. The Plan says the medications that you received are 
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D 
prescription drug plan. The Plan also says the medications you received are not covered under Medicare Part B. 
 
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 pay for the self-administered drugs 
provided from June 2, 2020, to June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 1, 2020, by an 
OON provider. 
 
You asked the Plan to pay for diagnostic injections. You say that the Plan should reconsider the enrollee's visit 
as payable. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on September 1, 
2020, by an OON provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MPI. 
 
You asked the Plan to pre-approve an MPI. You say that the requested MPI is medically necessary. The Plan 
denied your request. The Plan says that the requested MPI 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 an MPI. Our reviewer says that the 
requested MPI is medically necessary. Our physician reviewer found based on the records the enrollee has 
increased coronary risk, exertional dyspnea possibly due to an ischemic equivalent and no other clear cause for 
dyspnea on evaluation including physical exam and echocardiogram.  In this circumstance further evaluation 
with stress testing is reasonable, appropriate and consistent with accepted standards of medical practice.  
Current guidelines also consider nuclear stress test appropriate in this setting.  Coverage criteria are met 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 an MPI have been met. Therefore, we decided that the Plan has to pre-approve 
an MPI.  
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says the requested home health services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 home health services. Our reviewer 
says that the requested home health services are not medically necessary. Our physician reviewer found the 
enrollee is with a past medical history of hypertension, chronic obstructive pulmonary disease, chronic kidney 
disease and arthritis who had a fall on 11/22/2020 and sustained a fracture of her left distal radius which was 
treated with casting. A home health aide to assist with bathing 3 times a week for 2 months has been requested. 
 
Based on the medical records provided there is no documentation that the services meet the definition of home 
health aide services as per Sections A, B, C, D & E of Section 50.2. The enrollee has no skilled need for which 
she is receiving skilled home health services; home health aide services are not covered unless there is a skilled 
need and the patient is receiving skilled home health nursing or therapy services. There is no documentation 
that the home health aide services are reasonable and necessary for the treatment of the enrollees illness or 
injury by the skilled professional staff as there is no skilled need for which the enrollee is receiving skilled 
home health nursing or therapy services. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on February 6, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the provider rendered the services based on 
the enrollee's health condition. You also say that the service is covered by the Plan. The Plan denied your 
request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior 
authorization was not obtained. 
 
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 
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 nursing facility care provided on February 6, 
2020 by an OON provider.