Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you were 
provided on May 7, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 
copayment for nuclear medicine services in an outpatient hospital facility.  
 
Review of the file shows that you had myocardial perfusion imaging on May 7, 2020. You have been asked to 
pay a $350 copayment for the imaging. The imaging falls within the nuclear medicine 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 copayment for the myocardial perfusion imaging you were 
provided on May 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 molecular testing provided on July 21, 2020. 
 
You asked the Plan to pay for the testing. You say that you would like reconsideration because this testing is 
covered by Medicare. The Plan denied your request. The Plan says this service has not been billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that one unit of CPT code 81479 is used to report this 
testing.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the testing have not been met. Specifically, this testing has not been billed correctly. One unit of 
CPT code 81479 is used to report Guardant360 testing. Therefore, we decided that the Plan does not have to 
pay for Guardant360 molecular testing provided on July 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on July 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network 
services are not covered. 
 
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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on July 
16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a LINX procedure. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that you do not meet criteria for coverage of these services. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Your charting 
demonstrates worsening of symptoms when PPI therapy is discontinued, consistent with your at least 
substantial response to medical treatment of gastroesophageal reflux. Your pH testing fails to demonstrate 
consistent symptom correlation with acid reflux events, nor is there a significant gastroesophageal burden 
demonstrated by your calculated DeMeester score when off acid blocker therapy. Your manometry study 
documented that your LES tone is better than normal and thus does not require surgical augmentation by the 
LINX device (nor any other interventional anti-reflux technique). Your pre-op evaluation may be incomplete, 
particularly if an EGD has not been performed to show both resolution of gastric ulceration as well as absence 
of conditions (like Barrett's esophagus) for which the safety and efficacy of LINX has not been validated. Our 
physician reviewer found that your condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a LINX procedure.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for non-emergent, non-transport ambulance 
services (A0998) provided on July 31, 2020. 
 
You asked the Plan to waive the copayment for non-transport ambulance services. You say that you had never 
been charged for this service before. The Plan denied your request. The Plan says that there is no other claim 
on file for non-emergent, non-transport ambulance services associated with your account. The Plan also says 
that there is a $250 copayment for non-transport ambulance services according to the Plan?s 2020 EOC. 
 
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 $250 
copayment for Ambulance services.  
 
You have been asked to pay a $250 copayment for non-transport ambulance services. Non-transport ambulance 
services fall within the Ambulance 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 copayment 
for non-emergent, non-transport ambulance services (A0998) provided on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for outpatient surgery provided by THE PROVIDER on February 24, 2020. 
 
You asked the Plan to waive the deductible for outpatient surgery. You say that you were incorrectly charged 
The Plan denied your request. The Plan says the deductible was correctly applied. 
 
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 a $1,000 deductible for outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers. After you pay your $1,000 deductible, you pay: 
$350 copay for each Medicare-covered outpatient surgery. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This 
deductible is a contractual obligation that had not been met at the time outpatient surgery was received on 
February 24, 2020. Therefore, we decided that the Plan does not have to waive the deductible for outpatient 
surgery provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 10, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider 
on August 10, 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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. Finally, there is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and coinsurance for specialist office visits, 
outpatient tests and X-rays, and Euflexxa injections. 
 
You asked the Plan to waive the copayments and coinsurance for specialist office visits, outpatient tests and X-
rays, and Euflexxa injections. You say that you should not have to pay the copayment and coinsurance amounts 
because your therapy was incomplete due to COVID-19 shutdowns. The Plan denied your request. The Plan 
says the correct copayment and coinsurance amounts 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 $30 
copayment for specialist office visits, a 20% coinsurance amount for Part B Drugs, and a $0 copayment for 
diagnostic procedures, tests, and X-rays at your primary care physician?s office, or an $85 copayment amount 
at all other locations.  
 
You have been asked to pay $623.14 in total copayment and coinsurance amounts for multiple specialist office 
visits, outpatient tests and X-rays, and Euflexxa injections. Specialist office visits falls within the 
Physician/Practitioner services benefit category. Euflexxa injections (J7323) falls within the Medicare Part B 
prescription drugs benefit category. X-ray of the knee (73560), complete ultrasound of the leg (76881), and 
Fluoroscopic guidance for insertion of needle (77002) fall within the Outpatient diagnostic, tests and 
therapeutics 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 copayments and 
coinsurance for specialist office visits, outpatient tests and X-rays, and Euflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 14, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that your provider treated the member while 
hospitalized and they depend on the hospital staff to verify eligibility and obtain the proper authorization. The 
Plan denied your request. The Plan says no notes from your doctor have been sent showing why you needed 
this physician visit. 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 had network providers available who could have provided 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 medical services provided on July 14, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
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 had network providers 
available who could have provided the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-
network provider on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of continuous positive airway pressure 
device (CPAP). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no documentation that the machine is being used for the recommended amount 
of time each day. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found compliance with use of the device does not meet the minimum requirement of at least 70% of days with 
at least four hours of use. The data shows 5.6% of days with use of at least four hours. Use of the device is 
insufficient to provide significant benefit, so it is considered not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of continuous positive airway pressure device (CPAP).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services received August 
12, 2020. 
 
You asked the Plan to waive the copayment for emergency room services (99284). You say that a service was 
not provided to you by the treating physician. The Plan denied your request. The Plan says the correct 
copayment amount 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 $90 
copayment amount for Emergency Care.  
 
You have been asked to pay a $90 copayment amount for emergency room services (99284). Emergency room 
services (99284) falls within the Emergency 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 emergency room services (99284) received August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary and will 
benefit the enrollee's health. The Plan denied your request. The Plan says this could be done at an alternate 
level of care. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an ACH for fluid overload. 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. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
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 patient needs IRF care. The Plan denied your 
request. The Plan says rules for IRF care have 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Finally, there is not a reasonable expectation that this 
patient 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 18, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that the Plan should pay this claim. 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 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 services at issue in this appeal. The Plan did not pre-approve the service 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 the physician services provided on June 18, 2020 by an out of network provider.