Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that an LTACH is the best option for the 
enrollee's care. The Plan denied your request. The Plan says the enrollee's current needs are being met in the 
acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for newly 
diagnosed lung cancer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires 
services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, 
there is no advantage in transferring the enrollee to the LTACH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545, 
A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for 
swelling and that other stockings do not work for you. The Plan denied your request. The Plan says the 
compression stockings are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545, 
A6530 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
 
 
 
 
 
 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6545, A6530.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight testing provided on October 31, 2019. 
 
You asked the Plan to pay for the testing services. You say that the testing helps eliminate ineffective therapy. 
The Plan denied your request. The Plan says  
 
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing is only covered under certain 
medical indications.  
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records showing that that 
the enrollee has been diagnosed with major depressive disorder and is suffering with refractory moderate to 
severe depression after at least one prior neuropsychiatric medication failure. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pay for GeneSight testing provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) and for an 
ultrasound of blood flow in the head and neck (93880) on January 9, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit and an ultrasound of the head and neck. 
You say that you should not be charged multiple copayments per visit. The Plan denied your request. The Plan 
says the correct copayments were 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 $25 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays, and a $25 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $25 copayment for a specialist office visit and a $25 copayment for an 
ultrasound of the head and neck. A specialist office visit falls within the "Physician/Practitioner Services, 
Including Doctor's Office Visits" benefit category. An ultrasound of the head and neck falls within the 
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 office visit (99213) and for an ultrasound of blood flow 
in the head and neck (93880) on January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on January 8, 2020 
to February 19, 2020 by an out of network (OON) provider. 
 
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 the services were rendered by an out-of-network provider without 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 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 durable medical equipment provided on 
January 8, 2020 to February 19, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
first intraoral periapical x-ray (D0220) provided on March 10, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. 
You say that these services were due to a dental emergency. The Plan denied your request. The Plan says these 
services are not covered 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140) and first intraoral periapical x-ray (D0220) provided on 
March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 19, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urological supplies provided on October 16, 2019. 
 
You asked the Plan to pay for the urological supplies. You say that these should be covered by the Plan. The 
Plan denied your request. The Plan says that this is not separately reimbursed when the enrollee is in a SNF. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Medicare 
does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. 
 
Records show that the urological supplies were used in a SNF or hospital. The facility must furnish all 
necessary covered supplies to the beneficiary either directly or under arrangements made with outside 
providers. Theses supplies would have been included in the global payment submitted to the Plan by the 
facility. Therefore, we decided that the Plan does not have to pay for the urological supplies provided on 
October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses (V2025, V2100, V2750) provided April 1, 2020. 
 
You asked the Plan to pay for the eyeglasses. You say that the eyeglasses should be covered. The Plan denied 
your request. The Plan says the enrollee is responsible for the amount over $100. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. The total amount was $345.00. The plan contract states the enrollee 
is responsible for any amount over $100. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for 
eyeglasses (V2025, V2100, V2750) provided April 1, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Octreotide monthly injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the information available about this request does not indicate that it is safe and 
effective. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injections. Our reviewer says that 
the requested injections are medically reasonable and necessary. Our physician reviewer found the enrollee is 
at very high risk for recurrent GI bleeding with high morbidity and high cost. There are very limited treatment 
options. The requested treatment is considered non-invasive, reasonable, and 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 the injections have been met. Therefore, we decided that the Plan has to pre-
approve Octreotide monthly injections for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for aspiration and/or injection of large joint or 
joint capsule (20610) performed on February 24, 2020. 
 
You asked the Plan to waive the copayment for aspiration and/or injection of large joint or joint capsule. You 
say that you should only have to pay the copayment for a specialist office visit. The Plan denied your request. 
The Plan says the correct copayment was 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 $345 
copayment for a Medicare-covered surgery or other services provided to you at an ambulatory surgical center.  
 
You have been asked to pay $306.82 for aspiration and/or injection of large joint or joint capsule. Aspiration 
and/or injection of large joint or joint capsule falls within the "Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that 
you have been asked to pay less than the full 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 aspiration and/or injection of large joint or joint capsule (20610) 
performed on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 18, 
2020 through March 19, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review has determined that  the record did not show that at the time of inpatient 
admission the admitting physician reasonably expected that the patient's necessary hospital care (including 
earlier emergency department (ED) and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from March 18, 2020 through March 
19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on July 31, 2019. 
 
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 G0481 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 G0481 is definitive drug testing, 8-14 drug classes. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation 
of testing of 8-14 drug classes. 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 drug testing 
rendered on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on December 3, 2019 from an out-
of-network provider. 
 
You asked the Plan to pay for the eyeglasses. You say that when you used contracted services or asked about 
prices they were much higher than what you paid with this provider. 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 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 eyeglasses purchased on December 3, 2019 
from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit to your primary care 
provider (99215) on October 28, 2019. 
 
You asked the Plan to waive the copayment for an office visit to your primary care provider. You say that 
you've already fulfilled your cost sharing responsibility. The Plan denied your request. The Plan says the 
correct copayment was 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 $10 
copayment for services obtained from a primary care provider.  
 
You have been asked to pay a $10 copayment for an office visit to your primary care provider. An office visit 
to your primary care provider 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 an office visit to your primary 
care provider (99215) on October 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine home health skilled nursing visits. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says one visit is approved but nine further are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records do not show that the 
enrollee requires skilled nursing services to effectively provide treatment, care, and/or services in order to 
improve her condition, or to establish/perform a maintenance program to maintain her condition and/or prevent 
deterioration. She has had prior skilled nursing and was educated in disease management. There are no 
complex wounds, new enteral feedings, or other skilled nursing needs. Her wounds are healed and she does not 
require a skilled nurse in the home. The requested services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CT scans and a liver biopsy provided from 
September 18, 2019 to February 19, 2019. 
 
You asked the Plan to waive the coinsurance for CT scans and a liver biopsy. You say that you were told that 
the provider was in-network. 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 20% 
coinsurance for out-of-network CT scans and outpatient hospital surgery. 
 
 You received CT scans and a liver biopsy at an out-of-network provider, from September 18, 2019 to February 
19, 2019. Therefore, you are responsible to pay your share of the costs-sharing charges. 
 
The total amount you owe is: $1,185.40.  
 
You have been asked to pay the total coinsurance amount of $1,185.40 for CT scans and a liver biopsy. CT 
scans and a liver biopsy fall within the outpatient hospital 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 coinsurance for CT scans and a liver biopsy provided from September 18, 2019 to February 19, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee's care can be safely done in the current acute care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a 
hemorrhagic stroke while on anticoagulation following a recent ischemic stroke. The enrollee was 
intubated/ventilated upon presentation. The enrollee has since received a tracheotomy and appears to be 
tolerating some daytime ventilator weaning, but it is unclear if full ventilator weaning or decannulation are 
achievable. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.