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

 
We decided that the Plan does not have to pay for the pulmonary ventilation and perfusion imaging rendered on 
June 18, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that one unit of code 78582 is supported. There is no 
documentation to support further payment of this code. Therefore, we decided that the Plan does not have to 
pay for the pulmonary ventilation and perfusion imaging rendered on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173, 
80177, and 80201 provided on March 9, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical 
record. Specifically, the documentation does not support that Carbamazepine; free testing, Levetiracetam 
testing, Topiramate testing, Digoxin; total testing, Clozapine testing, or Haloperidol testing were performed 
with blood sampling. Blood specimen collection is by venipuncture; however, the lab requisition states a 
urine specimen was collected; therefore, the billed services cannot be verified. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided 
that the Plan does not have to pay for the laboratory services coded 80157, 80159, 80162, 80173, 80177, and 
80201 provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had on June 17, 
2020. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you are aware of the Plan's 
copayment waiver policy for telehealth visits that went into effect on July 1, 2020.  You said that because this 
visit was only 14 days before this policy went into effect that you should be given an exception and this 
copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 
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 $35 
copayment for telehealth services with a specialist.  
 
You have been asked to pay a $35 copayment for the telehealth visit. There is no provision in your contract for 
a waiver of this copayment. 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 telehealth visit you had 
on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 23, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
skilled nursing facility or the provider for these services. 
 
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 skilled nursing services provided on November 
23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services rendered on July 28, 
2020. 
 
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the deductible was applied correctly. 
 
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 there is $1,000 yearly deductible for your covered medical services.  
 
The item or service you asked the Plan to waive the deductible for falls within the out-of-network PCP office 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that 
had not been met at the time these services were received on July 28, 2020. Therefore, we decided that the Plan 
does not have to waive the deductible for the physician services rendered on July 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your physical 
function is very near baseline, and there are no noted skilled nursing needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer 
found that from a nursing perspective, you had stable vital signs, your lungs were clear, and you received oral 
medications. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a 
standby assist to contact guard assist level with functional mobility. Although there are identifiable skilled 
therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet 
severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy you had at an 
outpatient hospital facility on June 15, 2020. 
 
You asked the Plan to waive the copayment for the nasal endoscopy. You say that you have had this procedure 
in the past and have only had to pay a $20 copayment.  You also said that you had this procedure in an office, 
not in a hospital. The Plan denied your request. The Plan says you were charged this copayment 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 $100 
copayment for surgery or other services at an outpatient hospital facility.  
 
Records from this date of service indicate that you had this endoscopy in a treatment room at a clinic located 
within an outpatient hospital facility.  That is why this claim was billed as an outpatient hospital service. You 
have been asked to pay a $100 copayment for the nasal endoscopy. The nasal endoscopy falls within the 
surgery or other services at an outpatient hospital facility 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 nasal endoscopy you had at an outpatient hospital facility on June 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the port flush procedure and related drugs 
you received on February 25, 2020 at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the port flush procedure and related drugs. You say that you do 
not feel as though you owe this amount because the hospital staff did not tell you what they were going to give 
you. The Plan denied your request. The Plan says you were charged these copayments 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 $50 
copayment for Medicare Part B drugs and a $250 copayment for services at an outpatient hospital facility.  
 
You have been asked to pay a $250 copayment for the port flush procedure and a $50 copayment for the related 
drugs. 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 port flush procedure and related drugs you 
received on February 25, 2020 at an outpatient hospital facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot go to a skilled nursing facility 
due to being blind and the risk of Covid. The Plan denied your request. The Plan says the enrollee does not 
have any acute or new medical conditions. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for leg pain after a fall and had surgery to repair a torn 
tendon. His medical problems are stable. 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. 
There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. The medical record supports a need for physical and 
occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. 
 
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 rehabilitation services provided on June 18, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for rehabilitation services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that these services were not referred by a network provider or rendered in a participating facility. 
 
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 rehabilitation services provided on June 18, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 10, 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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the records show that blood sampling was performed; however, the specimens collected 
for the billed codes are not documented. 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 
laboratory services rendered on March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5259) purchased on August 21, 2020. 
 
You asked the Plan to pay for hearing aids. You say that you waited three years and were told this would be 
covered. The Plan denied your request. The Plan says three years had not yet passed when the hearing aids at 
issue were purchased. 
 
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 offers a 
$1,500 maximum allowance toward the cost of a hearing aid(s) every 3 years. 
 
We looked at the file and the Plan's rules. The record shows that you last received covered hearing aids on 
August 23, 2017. The hearing aids at issue were purchased less than 3 full years from this date. Based on this 
information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for hearing aids (V5259) purchased on August 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318). 
 
You asked the Plan to pre-approve Durolane (J7318). You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Part B coverage of the requested agent is subject to step therapy. Step 
therapy encourages you to try our preferred, equally effective agents. 
 
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 Durolane (J7318). Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation does not support 
that the required drugs would be less effective, and/or would likely have adverse effects for the enrollee in this 
case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane (J7318) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Durolane (J7318).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Avastin (J9035), Paclitaxel (J9267), Granisetron 
Hydrochloride (J1626), Dexamethasone (J1100), Famotidine (J3490), and Diphenhydramine (J1200). 
 
You asked the Plan to pre-approve Avastin, Paclitaxel, Granisetron Hydrochloride, Dexamethasone, 
Famotidine, and Diphenhydramine. You say that the drug therapy is medically necessary to treat the enrollee's 
condition. The Plan denied your request. The Plan says you do not meet the Medicare approved standards for 
drug coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Avastin, Paclitaxel, Granisetron 
Hydrochloride, Dexamethasone, Famotidine, and Diphenhydramine. Our reviewer says that the drugs requested 
are not FDA approved or supported by one of the major drug compendia or by clinical research that appears in 
a CMS-approved medical journal for the enrollee's diagnosis. Our physician reviewer found the enrollee has 
received 3 prior lines and progressed on both agents. The requested drug therapy is not supported in one of the 
major drug compendia or by clinical research in a patient who has progressed on both of these agents. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Avastin, Paclitaxel, Granisetron Hydrochloride, Dexamethasone, Famotidine, 
and Diphenhydramine have not been met. Therefore, we decided that the Plan does not have to pre-approve 
Avastin (J9035), Paclitaxel (J9267), Granisetron Hydrochloride (J1626), Dexamethasone (J1100), Famotidine 
(J3490), and Diphenhydramine (J1200).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Esophageal motility study (91010, A9270) provided on 
May 19, 2020. 
 
You asked the Plan to pay for the Esophageal motility study. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. 
 
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 Esophageal motility study (91010, A9270) 
provided on May 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is 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 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 based on the documentation provided, the health plan?s denial should be upheld. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
(15) hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at high risk for falls and loss of 
independence if he does not receive intensive multi-disciplinary therapy in an acute rehab setting. You also say 
that the enrollee requires continued supervision by a medical physician on a daily basis due to multiple 
comorbidities impacting his post-operative recovery. The Plan denied your request. The Plan says the request 
for IRF services is 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. Our reviewer found that the enrollee's care needs can be met at a lower level of care. 
 
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 IRF admission and services.