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

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan (70486) 
provided on September 23, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that the copayment was lower in previous 
years. The Plan denied your request. The Plan says this processed 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 $150 
copayment for diagnostic imaging.  
 
You have been asked to pay a $102.79 copayment for a CT scan, a diagnostic imaging service, because the 
allowed amount is less than $150. 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 computed 
tomography (CT) scan (70486) provided on September 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you do not agree with this copayment. 
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 $250 
copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital.  
 
You have been asked to pay $127.28 which is less than a $250 copayment for a CT scan. A CT scan falls 
within the outpatient diagnostic tests/advanced imaging services/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 a CT scan provided by a participating provider on May 26, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by Pittsford Volunteer 
Ambulance on August 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 30, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Pittsford 
Volunteer Ambulance on August 30, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for an electrocardiogram (93010) provided on June 11, 2020. 
 
You asked the Plan to pay for an electrocardiogram. You say that this was medically necessary. The Plan 
denied your request. The Plan says that Medicare does not pay any provider or supplier other than the facility 
or hospital for services furnished to the beneficiary while a patient. 
 
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. No documentation has been submitted to support that the enrollee was inpatient 
at the time of service or that this service was provided in connection to a surgery. Without this information, the 
denial is not substantiated. Therefore, we decided that the Plan has to pay for an electrocardiogram (93010) 
provided on June 11, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings and preventive 
procedure provided on September 4, 2020 by an OON provider. 
 
You asked the Plan to pay for the scalings and planings and preventive procedure. You say that you never 
received a provider book or Plan explanation of benefits. You also say that you contacted a Plan representative 
you gave you this provider's office and information. The Plan denied your request. The Plan says these services 
were rendered by an OON provider. The Plan also says that services performed by an OON provider are not 
covered because your healthcare plan does not have OON benefits. 
 
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 
covered when they are received OON. The record shows that you did not contact the Plan prior to the date of 
service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for 
the two periodontal scalings and root planings and preventive procedure provided on September 4, 2020 by an 
OON provider.  
 
Your complaint about possibly being misinformed by a Plan representative 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required, 
pontic, and two retainer crowns provided on October 7, 2020. 

You asked the Plan to pay for the core buildups, pontic, and retainer crowns. You say that you were not aware 
that the dentist needed an authorization prior to receiving these services. The Plan denied your request. The 
Plan says these services are not covered by your Health Plan or Medicare. The Plan also says that you signed a 
treatment plan with the provider on September 25, 2020, acknowledging that you would be fully responsible 
for the charges for these services. 
 
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 pay for the two 
core buildups, including any pins when required, pontic, and two retainer crowns provided on October 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on July 25, 2020. 
 
You asked the Plan to pay for the ambulance transport. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
member?s terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on July 24, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance transport 
provided on July 25, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel One knee injections. 
 
You asked the Plan to pre-approve the Gel One injections. You say that you have a high level of pain and need 
this approved as soon as possible. The Plan denied your request. The Plan says there is no evidence that the 
plan's preferred drugs would not be appropriate. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel One injections. Our reviewer 
says that the requested drug is not considered reasonable and necessary based on step therapy rules. Our 
physician reviewer found the enrollee has not trialed one viscosupplemental treatment such as Orthovisc and 
Monovisc. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation 
does not outline contraindications or reasons these medications were not considered. Without the support of the 
documentation, Gel-One is not approved as step criteria have not been met. 
 
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 Gel One injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gel One knee injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department visit 
 
You asked the Plan to pay for the emergency department visit. You say that the information provided shows 
proof of your due diligence to meet the filing requirements. The Plan denied your request. The Plan says the 
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 valid claim for the emergency department visit was not filed until August 20, 2020. 
The documentation you provided was not sufficient in showing that a valid claim was delivered to the Plan 
within 12-months of the date of service in dispute. 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 
emergency department visit
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for breast panel testing provided on December 8, 2019. 
 
You asked the Plan to pay for testing. You say that this testing was medically necessary to assist in 
the treatment, prognosis, and diagnosis if their cancer. The Plan denied your request. The Plan says that the 
denial of payment for this testing is correct because this testing is experimental/investigational and 
authorization was not obtained. 
 
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 pay for testing. Our reviewer says that 
this testing meets the criteria for coverage. Our physician reviewer found patients with inflammatory and 
metastatic breast cancers benefit from next generation sequencing to identify markers that may indicate benefit 
from targeted treatment or clinical trials. The enrollee has exhausted several prior lines of therapy but maintains 
a good functional status. The use of this testing is medically reasonable and 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 testing have been met. Therefore, we decided that the Plan has to pay 
for breast panel testing provided on December 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional three home health physical therapy (PT) 
visits. 
 
You asked the Plan to pre-approve the additional home health PT visits. You say that you feel that the total 
number of requested visits are necessary. The Plan denied your request. The Plan says six additional visits are 
sufficient to meet your needs. 
 
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 the additional home health PT visits. 
Our reviewer says that the documentation does not support the medical necessity of the number of requested 
visits. Our physician reviewer found the enrollee is an 86-year-old woman with a history of diabetes, diabetic 
neuropathy, and hypertension, who has been receiving physical therapy and skilled nursing in her home. The 
plan approved six additional PT visits. Three PT visits were denied. On 1/7/21, the enrollee was ambulating 40 
feet with a rollator. The enrollee requires contact guard assistance with toileting, sit to stand, and stand to sit. 
The documentation does not demonstrate that the additional skilled therapy services are required to effectively 
provide treatment, care, and/or services in order to improve the enrollee's level of function, or to 
establish/perform a maintenance program to maintain the patient's level of function and/or prevent 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 additional home health PT visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an additional three home health physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wig provided. 
 
You asked the Plan to pay for the wig. You say that you would like reconsideration because this service was 
not cosmetic surgery and you purchased the wig because your provider explained that you would lose your 
hair. The Plan denied your request. The Plan says cosmetic surgery is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need rehab. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the records show that you were 
admitted to the hospital on January 5, 2021. The progress note dated January 14, 2021 states you felt fine and 
your wounds were stable. The records show that you do not require the intensity of services provided at an IRF. 
Specifically, you do not require fifteen hours per week of rehabilitative services and regular physician 
evaluation. The IRF services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a penile injection (54235) provided on June 
11, 2020. 
 
You asked the Plan to waive the copayment for a penile injection. You say that you did not know this would be 
considered surgery. The Plan denied your request. The Plan says this processed 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 $325 
copayment for outpatient hospital surgery services.  
 
You have been asked to pay a $304.50 copayment for a penile injection, which is considered an outpatient 
hospital surgery service, because the allowed amount is less that $325. 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 penile injection (54235) provided on June 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 14, 2020. 
 
You asked the Plan to pay for the lab services. 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulation services received on September 29, 
2020. 
 
You asked the Plan to pay for the electrical stimulation services. 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. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the electrical stimulation services received on September 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on June 26, 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 procedure code 33641 is not supported. 
 
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 code 33641 is repair atrial septal defect, secundum, with 
cardiopulmonary bypass, with or without patch. 
 
We find that CPT code 33641 is not supported in the medical record. Specifically, the operative report contains 
no documentation of a repair of an atrial septal defect. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the surgical services rendered on June 26, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services you 
received on July 28, 2020. 
 
You asked the Plan to waive the copayment. You say that you usually have a $30 copayment when this is done 
in the office. The Plan denied your request. The Plan says you are responsible for the 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 $350 
copayment for outpatient surgery in a freestanding ambulatory surgical center.  
 
Review of the file shows that you were provided surgical services on July 28, 2020. You have been asked to 
pay a $350 copayment for the services. The 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 surgical services you received on July 28, 
2020.