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, with 
quantitative evaluation of coronary calcium (75571). 
 
You asked the Plan to pre-approve this service. You say that a CT scan of the heart, with quantitative 
evaluation of coronary calcium is medically necessary. The Plan denied your request. The Plan says the 
requested CT scan of the heart is not medically necessary. 
 
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 this service. Our reviewer says that a 
CT scan of the heart, with quantitative evaluation of coronary calcium is not medically necessary. Our 
physician reviewer found that you have been noted to have elevated cholesterol, which has previously been 
untreated. There is no evidence of clinical symptoms, abnormal electrocardiograms or prior cardiac testing. The 
requested CT scan is not necessary to treat the elevated cholesterol or to evaluate any signs or symptoms. The 
documentation does not show that the requested CT scan is currently medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart, with quantitative evaluation of coronary 
calcium (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee. 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says care can be provided in a less intensive setting, for example: a skilled nursing facility. 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure, pneumonia and kidney failure. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There 
is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the cost share for the services provided. We decided that the Plan does 
not have to reduce the cost share for the services provided.  
 
You asked the Plan to reduce the cost share for the services provided. You say that you were told your copay 
would be $295. The Plan says that the claim processed correctly per the benefit plan. 
 
We decided that the Plan has to reduce the cost share for the services provided.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). 
 
The file shows that you received outpatient surgery services from an in-network provider. Your contract with 
the Plan clearly says that you must pay a $295 copay for surgery services from an in-network provider. 
Therefore, we decided that the Plan has to reduce the cost share for the services provided on December 31, 
2019.  
 
 
We also decided that the Plan does not have to completely waive the cost share for the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance).  
 
The services fall within the outpatient surgery benefit category. 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 
completely waive the cost share for the services provided on December 31, 2019. 
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on January 23, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you have never had a 
copayment for this before. 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 $30 
copayment for physician/practitioner services/in-network/specialist office.  
 
You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within 
the physician/practitioner services/in-network/specialist office 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 provided by a participating provider on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service provided on July 14, 2020. 
 
You asked the Plan to pay for the ambulance service (A0998). You say that you were transported so the bill 
should be paid. The Plan denied your request. The Plan says if you are not transported then no coverage by the 
Plan.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport. In this case, the CPT Code Manual definition of code A0998 is Ambulance response and 
treatment, no transport. 
 
The provider submitted the claim as treatment no transport. The ambulance benefit is a transportation benefit. 
When there is no transport, neither Medicare nor the Plan pays for the services provided. In this case the code 
submitted on the clam is excluded from payment under Medicare Guidelines. Therefore, we decided that the 
Plan does not have to pay for the ambulance service provided on July 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating 
provider on July 16, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you have never paid separately for these 
services. 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 $200 
copayment for outpatient diagnostic tests/outpatient x-rays/outpatient hospital.  
 
You have been asked to pay $99.74 which is less than your copayment amount of $200 for an x-ray. An x-ray 
falls within the outpatient diagnostic tests/outpatient x-rays/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 an x-ray provided by a participating provider on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the intravenous moderate (conscious) sedation/analgesia-first 15 
minutes (D9239) and the intravenous moderate (conscious) sedation/analgesia-each subsequent (D9243).  
We also decided that the Plan does not have to pre-approve the therapeutic parenteral drug, single 
administration (D9610) and the unspecified preventive procedure (D1999).  
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan says that the services requested are not a covered benefit under your contractual policy. 
 
We decided that the Plan has to pre-approve the intravenous moderate (conscious) sedation/analgesia-
first 15 minutes (D9239) and the intravenous moderate (conscious) sedation/analgesia-each subsequent 
(D9243). The services requested are listed in the benefits chart of your dental policy. Additionally, as a 
member of the Plan, enrollees may obtain services from in-network or out of network providers. Therefore, we 
decided that the Plan has to pre-approve the intravenous moderate (conscious) sedation/analgesia-first 15 
minutes (D9239) and the intravenous moderate (conscious) sedation/analgesia-each subsequent (D9243).  
 
We also decided that the Plan does not have to pre-approve the therapeutic parenteral drug, single 
administration (D9610) and the unspecified preventive procedure (D1999). These services requested are 
not listed in the benefits chart of your dental policy. If a service is not listed in the benefits chart of the Plan 
dental contract, it is not covered. Therefore, we decided that the Plan does not have to pre-approve these 
services. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of ranibizumab (J2778) provided on June 25, 2020.

You asked the Plan to waive the coinsurance for an injection. You say that you were unaware there was a cost share. The Plan denied your request. The Plan says the cost share was applied 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 20% coinsurance for Medicare Part B prescription drug coverage. 

You have been asked to pay a 20% coinsurance for an injection. This service falls within the Medicare Part B prescription drug coverage 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 an injection of ranibizumab (J2778) provided on June 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
August 3, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care and the services 
were not ordered by a plan contract physician. 
 
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 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 out of network lab services 
provided to the enrollee on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the radiation services provided on July 24, 
2020. 
 
You asked the Plan to waive the copayment for the radiation services. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received radiation therapy on the date of service at issue in this appeal. The 
Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $60 
copayment per visit for radiation therapy.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received radiation therapy 
on July 24, 2020. You have been asked to pay a $60 copayment for the radiation services. The radiation 
services fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the radiation services provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning (D4341). 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the member has exhausted their maximum plan 
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. Records show you received this service on December 30, 2019. This 
means you have exhausted you maximum benefit frequency. Therefore, we decided that the Plan does not have 
to pre-approve deep gum and root cleaning (D4341).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health skilled nursing services. 
 
You asked the Plan to pre-approve the requested services. You say that you need a nurse to flush your port. The 
Plan denied your request. The Plan says there are no orders that indicate there is a skilled need. 
 
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 requested services. Our physician 
reviewer found that the provided records do not indicate that you have a medical port, that the port is having 
problems, that the port is being used for regular medication administration, or that a visiting home nurse is 
required to use or maintain the port. As such, the documentation does not support that the requested service is 
currently medically necessary or reasonable. 
 
 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health skilled nursing services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 31, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services must be 
billed to Original Medicare. 
 
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 August 5, 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 the services provided 
on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the personal protective equipment (PPE) (D1999) 
provided on June 3, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that there was a $10 charge for your 
protection from Covid-19. You also say that reimbursement should be paid. The Plan denied your request. The 
Plan says personal protective equipment (PPE) is not a covered service. 
 
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 reimburse you for 
the personal protective equipment (PPE) (D1999) provided on June 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no complex medical or intensive rehabilitation needs requiring supervision by 
a rehab physician. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for coronary artery bypass grafting and aortic valve replacement. Medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for lab services provided by July 15, 2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says that these services are not covered by Medicare and therefore were not 
paid. 
 
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 rules also say any services ordered by a Plan contract provider are retrospectively covered by the 
Plan. There were no medical records included with your appeal. The Plan did not confirm the lab services were 
ordered out of network; therefore, it is our assumption they were ordered by your primary care physician, a 
plan provider. There is no indication in the case file that you were made aware that these lab services would not 
be covered prior to the service being rendered.  The Plan has not made reasonable and diligent efforts to gather 
and forward to us information regarding their decision to deny your request.  Therefore, we decided that the 
Plan has to pay for lab services provided on July 15, 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.