Persius/hicric huggingface dataset:
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services are not medically necessary. Our physician reviewer found the enrollee does not need 
supportive devices or special transportation in order to leave her place of residence, and the documentation 
does not support that leaving her home is contraindicated. The enrollee can be reasonably treated in an 
outpatient 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a PET scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that PET imaging is not supported for initial staging of prostate cancer. 
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found biochemically, this 
enrollee most certainly has prostate cancer due to the markedly elevated PSA levels despite the administration 
of Lupron. His most recent imaging studies including bone scan were in 2019 and showed no evidence of 
metastatic disease. The CT of the pelvis revealed mild to moderate prostate enlargement but no pelvic 
adenopathy was described. The patient also has diminished renal function and a low left ventricular ejection 
fraction. These comorbidities apparently preclude IV contrast administration which limits CT evaluation. 
Axumin PET is prostate specific and the scan would provide the most detailed and sensitive means with which 
to evaluate the patient. Rather than repeat all the conventional imaging studies as the most recent were in 2019 
the best test for this enrollee whom has failed androgen deprivation therapy would be Axumin PET/CT. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
a PET scan for the enrollee.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical service 
(90792) provided on March 1, 2019. 
 
You asked the Plan to pay for psychiatric diagnostic evaluation. You say that you did not receive proper notice 
of the member's benefit determination timely. The Plan denied your request. The Plan says you submitted the 
claim after the timely filing deadline. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for psychiatric diagnostic evaluation was not filed until September 8, 2020. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for psychiatric diagnostic evaluation with medical 
service (90792) provided on March 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 19, 2019.

You asked the Plan to waive the copayment for the ultrasound. You say that you were never told you would have a $50 copayment. You say you would not have gotten it done. The Plan denied your request. The Plan says the claim had been reprocessed and you have been charged the correct cost sharing 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 $50 copayment for all other diagnostic tests. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ultrasound is considered a diagnostic test.

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 ultrasound provided on September 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided 
March 2, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was filed past 
the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the psychiatric diagnostic evaluation was not filed until August 31, 2020. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) 
provided March 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pulp cap (D3120) provided on August 26, 2020. 
 
You asked the Plan to pre-approve the pulp cap. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this service is not covered under your 
supplemental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
pulp cap (D3120) provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral X-ray (D0230) provided June 9, 
2020. 
 
You asked the Plan to pay for the additional intraoral X-ray. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the benefit has been 
exhausted for the services requested. 
 
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 additional 
intraoral X-ray when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that the Plan previously approved payment for one 
additional intraoral X-ray billed on the same date. This would mean that the claim has been exhausted for the 
additional intraoral X-ray. Based on this information, we decided that the Plan's rules for coverage of the 
additional intraoral X-ray have not been met. Therefore, we decided that the Plan does not have to pay for the 
additional intraoral X-ray (D0230) provided June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on February 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you do not have out-
of-network benefits. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on February 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further reimburse you for the complete denture - maxillary (D5110) 
and complete denture - mandibular (D5120) provided August 25, 2020. 
 
You asked the Plan to further reimburse you for the complete denture - maxillary and complete denture - 
mandibular. You say that you would like this claim to be reprocessed. The Plan denied your request. The Plan 
says the $150 benefit has been applied correctly and no further reimbursement is due. 
 
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 complete 
denture - maxillary and complete denture - mandibular when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. The file indicates that the Plan has reimbursed you $150 for the 
services received. You are responsible for the remaining charges. Based on this information, we decided that 
the Plan's rules for coverage of the complete denture - maxillary and  complete denture - mandibular have 
processed correctly. Therefore, we decided that the Plan does not have to further reimburse you for the 
complete denture - maxillary (D5110) and complete denture - mandibular (D5120) provided August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for tendon sheath injections provided on 
September 16, 2020, and October 14, 2020. 
 
You asked the Plan to waive the copayments for tendon sheath injections. You say that you disagree with the 
charges because your physician recommended the injections. 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 $300 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received a tendon sheath injection at an outpatient hospital facility, on September 16, 2020. Therefore, you 
are responsible to pay the $300 copayment.   
 
You received a tendon sheath injection at an outpatient hospital facility, on October 14, 2020. Therefore, you 
are responsible to pay the allowed amount of $236.45, which is less than the $300 copayment.  
 
The total amount you owe is: $536.45.  
 
You have been asked to pay the total copayment amount of $536.45 for tendon sheath injections. Tendon 
sheath injections fall within the outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers 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 
tendon sheath injections provided on September 16, 2020, and October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the therapeutic program you need was not 
available at the in-network provider. The Plan denied your request. The Plan says there are in-network 
providers within a reasonable distance that can provide the appropriate therapy. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the screening mammogram provided on 
December 19, 2019. 
 
You asked the Plan to waive the coinsurance for the screening mammogram. You say that you were not aware 
that the provider was out-of-network. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing 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 50% 
coinsurance for an out-of-network Medicare-covered preventive screening.  
 
You have been asked to pay $99.81 which is 50% of the allowed amount for the screening mammogram. The 
allowed amount is $199.62. ($199.62 x 50% = $99.81). The screening mammogram falls within the "Breast 
cancer screening (mammogram)" benefit category. The record shows this provider is out-of-network. 
 
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 the screening mammogram provided on December 19, 
2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on September 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for eleven sessions of outpatient cardiac 
rehabilitation therapy (93798) provided from September 1, 2020, to September 30, 2020. 
 
You asked the Plan to waive the copayments for the cardiac rehabilitation therapy. You say that you were told 
you would not have any out of pocket costs for these services. The Plan denied your request. The Plan says 
cardiac rehabilitation services have a $10 copayment. 
 
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 cardiac rehabilitation services.  
 
You have been asked to pay a $10 copayment for each session of cardiac rehabilitation therapy ($10 x 11 
sessions = $110). Cardiac rehabilitation therapy falls within the cardiac rehabilitation 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 copayments for eleven sessions of outpatient cardiac rehabilitation therapy 
(93798) provided from September 1, 2020, to September 30, 2020.  
 
Your complaint about being provided inaccurate information is not a valid appeal for medical coverage. This 
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy for levels L3-L4 with fusion from L1-L5. 
 
You asked the Plan to pre-approve the spinal surgery. You say that the requested surgery is needed to address 
the enrollee's continued pain and functional issues. Fusion will be required as the other necessary services will 
lead to spinal instability. The Plan denied your request. The Plan says the requested procedure 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 the spinal surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documented spinal instability or severe deformity. There is no documented exam 
findings of significant neurological deficit. Criteria for lumbar decompression and multilevel fusion are not 
met. This surgery is not needed. 
 
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 spinal surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve laminectomy for levels L3-L4 with fusion from L1-L5.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for a drug test. You say that you would like this claim reprocessed and paid. The 
Plan denied your request. The Plan says these services were not authorized by a network/primary care 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 had network providers 
available who could have provided 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 a drug test provided on September 16, 2020 by an 
out of network (OON) provider.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy services (G0151) and skilled nursing care 
(G0299) from an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that home health care is medically necessary. 
The Plan denied your request. The Plan says that the home health agency is not certified with Medicare. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 this service is medically necessary. Our physician reviewer found the documentation does support that 
the member requires skilled nursing services and skilled rehab services to provide treatment that is medically 
necessary. The member does require skilled nursing or rehab services to effectively provide treatment, care, 
and/or services in order to improve the member's condition, perform a maintenance program to maintain the 
member's condition and/or prevent deterioration.  The member has had a decline in functional status and has a 
new medical condition that is requiring complex treatment with chemotherapy. 
 
The provider is a non-contract provider. We were able to confirm that the requested home health agency is a 
Medicare certified provider. We were able to confirm that the Plan does not have contract providers located 
within reasonable distance from the enrollee's home address. They have indicated that there are no alternative 
home health agencies able to provide the level of care the enrollee needs. Under Medicare rules, this means that 
contract providers are not accessible to you. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve physical therapy services (G0151) and skilled nursing care (G0299) from an out-of-network 
(OON) provider.  
 
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.