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

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart (75571). 
 
You asked the Plan to pre-approve a CT scan of the heart. 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. Medicare rules say that CT 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 a CT scan of the heart. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found you have no symptoms of 
cardiac disease documented in the records. A recent electrocardiogram (EKG) was normal and you were found 
to have normal sinus rhythm. The requested exam is for risk stratification. CT coronary calcium scoring is 
considered a screening test by CMS and is thus not a covered examination per CMS guidelines. 
 
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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart (75571).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrocardiographic monitoring provided on May 26, 2020. 
 
You asked the Plan to pay for the electrocardiographic monitoring. 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 electrocardiographic monitoring provided on May 26, 2020.
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 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 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 you are medically stable with no documented evidence of complex medical issues 
that require monitoring by an inpatient physical, medicine, and rehabilitation (PMR) physician three times per 
week or need for acute rehab nursing care. While you may benefit from continuing physical therapy (PT) and 
occupational therapy (OT), there is no evidence of need for an intensive therapy program with therapy 3 hours 
per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. Admission to 
IRF is not medically necessary based on lack of medical complexity. You have had therapy at a skilled nursing 
facility (SNF) for a long time and do not need IRF level of therapies. Your rehab needs can be met at an 
alternate, low intensity level setting such as in-home with 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 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 pay for a chiropractic office visit (99201) and electrical stimulation 
(G0283) provided on May 20, 2020. 
 
You asked the Plan to pay for a chiropractic office visit  and electrical stimulation. You say that this was 
medically necessary to treat your pain. The Plan denied your request. The Plan says these services are not 
covered when performed by a chiropractor. 
 
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 a chiropractic office visit (99201) and electrical stimulation (G0283) provided 
on May 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. You say that you would like reconsideration because 
the member's activities of daily living have been affected due to the decline in visits. The Plan denied your 
request. The Plan says the requested services are considered maintenance therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic services. Our reviewer says 
that the chiropractic treatments requested are to prevent deterioration of a chronic condition, with no evidence 
of clinical improvement or that clinical improvement will occur from continuous ongoing care. Our physician 
reviewer found the treatments are maintenance therapy and are not supported or allowed per Medicare 
guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on November 14, 2019. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says out 
of network providers require 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 nurse practitioner services provided on November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 5, 2020. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one 
unit of CPT 81479 and the appropriate DEX Z-Code.  
 
We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT 
codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for an annual wellness exam provided on June 11, 2020. 
 
You asked the Plan to waive the copayment for an annual wellness exam. You say that this was an annual 
wellness exam and you should not owe a copayment. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay there is no coinsurance, copayment or deductible for annual 
wellness visits.  
 
The medical records provided indicate that you received an annual wellness exam on June 11, 2020. There was 
no indication that services beyond an annual wellness exam took place. Therefore, you cannot be asked to pay 
anything for the visit.  
 
The Plan says you must pay a $15 copayment for an annual wellness exam. Based on the Plan contract, 
however, you cannot be asked to pay for an annual wellness exam. Therefore, we decided that the Plan has to 
waive the copayment for an annual wellness exam 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 6, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with 
the appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 6, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on May 
6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from February 
13, 2020, to February 24, 2020. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that you did not know that you were 
inpatient. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $200 
copayment per day for days 1-7 for each Medicare-covered hospital stay.  
 
You have been asked to pay a $1,400 copayment for the first seven days of your inpatient stay ($200 x 7). An 
inpatient stay falls within the inpatient hospital care 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 an inpatient stay provided from February 13, 2020, to February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Part B drug injection provided on May 
15, 2020. 
 
You asked the Plan to waive the copayment for a Part B drug injection. You say that you needed this service 
and the circumstances were out of your control. The Plan denied your request. The Plan says the copayment 
you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs.  
 
The allowed amount of the claim is $1,091.38, resulting in a coinsurance obligation of $218.28 for a Part B 
drug injection ($1,091.38 x 20%). Part B drug injections fall within the Medicare Part B prescription drugs 
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 Part B drug injection provided 
on May 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on April 11, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you had fallen from low blood sugar. 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 April 11, 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 on April 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 25, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory 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 laboratory services provided on March 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Radiologic examination, professional component provided 
on May 29, 2020. 
 
You asked the Plan to pay for Radiologic examination, chest; 2 views. You say that the enrollee had multiple 
exams on this date of service. The Plan denied your request. The Plan says this is a duplicate service already 
paid for. 
 
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, a claim for the same service for the same enrollee on the same date of services was previously paid 
to a physician in the same practicing group. The second claim submitted does not contain a modifier or 
documentation that indicates this was a separate and distinct services.  
 
Based on this information, we decided that Medicare rules for coverage of Radiologic examination, chest; 2 
views have not been met. Therefore, we decided that the Plan does not have to pay for Radiologic examination, 
professional component, provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921), comprehensive oral 
evaluation (D0150), and complete series of intraoral x-rays (D0210) provided on May 26, 2020. 
 
You asked the Plan to pay for the gingival irrigation, comprehensive oral evaluation, and complete series of 
intraoral x-rays. You say that you had to switch dentists because your previous dentist no longer accepted your 
insurance plan. You also say that you were due for a cleaning. The Plan denied your request. The Plan says 
gingival irrigation is not covered under the Plan. The Plan also says that the comprehensive oral evaluation and 
complete series of intraoral x-rays exceed the maximum count allowed per period.  
 
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, gingival irrigation (D4921) is not 
among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) and 
complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The 
record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-
rays (D0210) on December 6, 2019, and your comprehensive oral evaluation (D0150) and complete series of 
intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to 
pay for the gingival irrigation (D4921), comprehensive oral evaluation (D0150), and complete series of 
intraoral x-rays (D0210) provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of test materials and equipment for home INR 
monitoring provided on January 29, 2020. 
 
You asked the Plan to pay for provision of test materials and equipment for home INR monitoring (G0249). 
You say that the Plan should pay this claim. The Plan denied your request. The Plan says the test frequency has 
been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that testing should not occur more frequently than 
once a week and billing units of service include 4 tests. 
 
We find that 1 unit of CPT code G0249 was billed and paid for date of service January 23, 2020. The supplies 
at issue were billed before day 25. Based on this information, we decided that Medicare rules for coverage of 
provision of test materials and equipment for home INR monitoring (G0249) have not been met. Therefore, we 
decided that the Plan does not have to pay for provision of test materials and equipment for home INR 
monitoring provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing exam and hearing aids provided by an out-of-
network provider on January 30, 2020. 
 
You asked the Plan to pay for a hearing exam and hearing aids. You say that you realized you weren't hearing 
well in the hospital and made an appointment at the nearest hearing provider. The Plan denied your request. 
The Plan says hearing services are only covered from plan providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased from plan providers.  
 
We looked at the file and the Plan's rules. The items and services at issue were not purchased from the Plan's 
hearing vendor. Based on this information, we decided that the Plan's rules for coverage of a hearing exam and 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for a hearing exam 
and hearing aids provided by an out-of-network provider on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out of network provider, 
on March 21, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care service (99309). You say that the facility did 
not obtain the proper authorization. The Plan denied your request. The Plan says you did not request 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 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 services. Therefore, we decided that the Plan does not have to pay for the medical 
services provided by an out of network provider, on March 21, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2020.

You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed claim is for a nonparticipating Home Health provider and the RAP claim was not submitted.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the records do not indicate that a RAP was submitted. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from May 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulator supplies (A4595) and lumbar-sacral orthosis (L0650) provided on March 26, 2020.

You asked the Plan to pay for the DME. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted does not include an itemized billing/shipping invoice to indicate the specific supplies or proof of delivery.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record does not include a shipping/billing invoice to indicate the specific supplies delivered or a valid proof of delivery ticket for the billed date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies (A4595) and lumbar-sacral orthosis (L0650) provided on March 26, 2020.