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

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 28, 
2020. 
 
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary or rest home visit provided on February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing services provided on February 5, 2020.
You asked the Plan to pay for the services provided. You say that the provider ordered the testing to determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan says comprehensive genomic profile testing requires the use of CPT 81479.
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 the claim provided does not show that the coding and billing guidance has been followed. Based on the information provided, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing services provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that the Plan had approved all of the services you need. You also say that denying these two services puts the Plan in default for not complying with your contract agreement. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 pre-approve a custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (36415, 86580, 90791, 90832, 90837, 
90853, 96130, 96150, 96151, 96512, 96513, 96161, 97110, 97530, 97533, 97535, 97537, 99204, 99205, 99213, 
99214, 99306, 99310, 99316, 99407, 99447, 99484, 99409) provided from September 13, 2019 to September 
19, 2019. 
 
You asked the Plan to pay for medical services. You say that these services should be covered. The Plan denied 
your request. The Plan says these services were provided by a provider that is not certified for Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program.  
 
We looked at the file and Medicare rules. The services at issue were provided by a provider that is not enrolled 
in the Medicare program. Based on this information, we decided that Medicare rules for coverage of medical 
services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services 
(36415, 86580, 90791, 90832, 90837, 90853, 96130, 96150, 96151, 96512, 96513, 96161, 97110, 97530, 
97533, 97535, 97537, 99204, 99205, 99213, 99214, 99306, 99310, 99316, 99407, 99447, 99484, 99409) 
provided from September 13, 2019 to September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
March 3, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to 
determine if there was a more effective therapy to treat the enrollee. The Plan denied your request. The Plan 
says the denial of payment for this testing is correct, because this testing was not billed with the appropriate 
coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service March 3, 2020.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for 
comprehensive genomic profile (CGP) testing provided on March 3, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care.
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. The
patient is medically stable with newly diagnosed multiple sclerosis with left side weakness with no evidence of
need for supervision by physical medicine and rehab physician or need for acute rehab nursing care.
Functionally given his current level, though he needs physical therapy (PT) and occupational (OT), he does not
require IRF level of therapies. The patient may benefit from further PT and an OT but does not require an
intensive therapy program. IRF admission is not medically necessary based on the patient's current functional
status and lack of medical complexity. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS. You say that the results of the CardioMEMS study 
demonstrated the effectiveness and safety of the procedure. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because studies have not proven that this device is helpful for 
treatment of the enrollee's condition. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found therapy change based on data obtained from a CardioMEMS device has been demonstrated in 
only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns 
have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the 
CardioMEMS device is uncertain at this time and not recommended in current guidelines for the treatment of 
heart failure. This device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a CardioMEMS device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
March 12, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis 
(L0650) provided to the enrollee on March 12, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for a skilled nursing stay. We decided that the Plan does 
not have to waive the coinsurance for a skilled nursing stay.  
 
You asked the Plan to waive the coinsurance for a skilled nursing stay. You say that you were given 
misinformation. The Plan says that the correct coinsurance has been applied. 
 
We decided that the Plan has to reduce the coinsurance for a skilled nursing stay.  
 
You cannot be charged more than a 10% coinsurance for a skilled nursing facility stay. The total allowed 
amount is $12,479.09. The total amount that you should be asked to pay is $1,247.91 ($12,479.91 x 10% = 
$1,247.91). Therefore, we decided that the Plan has to reduce the coinsurance for a skilled nursing stay.  
 
 
 
 
 
 
We also decided that the Plan does not have to waive the coinsurance for a skilled nursing stay. 
 
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% 
coinsurance for a skilled nursing stay. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a skilled nursing stay. 
 
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: 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 these services are medically necessary. 
The Plan denied your request. The Plan says that your 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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You are 
currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. You were intubated/ventilated 
and subsequently received a tracheotomy. You have since been weaned from the ventilator. There is no 
evidence that you require 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 you to the LTACH. You can remain at the 
current ACH until such time no acute services are required. You can then be transferred/discharged to a lower 
level of care for any ongoing long term care needs. Our physician reviewer found that your condition does not 
meet Medicare criteria for LTACH 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 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 pay for a knee orthosis with suspension sleeve (L1833, L2397) 
provided to the enrollee on January 14, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a 
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an 
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was 
performed. The information submitted does not confirm that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, 
L2397) provided to the enrollee on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physician services provided by an out-of-
network provider on January 17, 2020 to February 14, 2020. 
 
You asked the Plan to waive the deductible for physician services. You say that you did not know that this 
provider was out-of-network. The Plan denied your request. The Plan says the correct deductible amount has 
been 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 $750 deductible for physician/practitioner services/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is a $750 deductible and a 45% coinsurance of the allowed amount for 
physician/practitioner services/out-of-network and a $50 copayment for physician/practitioner services/in-
network/specialist services. The total allowed amount is $172.77. The total coinsurance amount is $77.73 
($172.77 x 45% = $77.73). The total amount you are being asked to pay is $877.73 ($750 + $77.73 + $50 = 
$877.73). This cost sharing is a contractual obligation that had not been met at the time physician services was 
received on January 17, 2020 to February 14, 2020. Therefore, we decided that the Plan does not have to waive 
the deductible for physician services provided by a participating provider on January 17, 2020 to February 14, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve chemotherapy administration. You say that you are appealing. The Plan 
denied your request. The Plan says the denial of authorization for this service is correct, because although the 
Plan agrees that the service is medically necessary, the requested provider is out-of-network with the Plan and 
the enrollee can be treated by an in-network provider. The Plan also says that they will authorize 1 visit for 
chemotherapy administration with the out-of-network provider, during which time the enrollee can transition to 
care with an in-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4222, J2260) provided from November 25, 2019 to December 1, 2019.
You asked the Plan to pay for infusion supplies. You say that these supplies should be paid for. The Plan denied your request. The Plan says the delivery ticket indicates different dates of service than what was billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. As a general Medicare rule, the date of service shall be the date of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery documentation does not corroborate the dates of service billed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for infusion supplies (A4222, J2260) provided from November 25, 2019 to December 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on February 26, 2020.
You asked the Plan to pay for genetic testing. You say that the treating physician ordered this testing to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT code 81479 for date of service February 26, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on February 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for infusion drugs, an emergency room visit, 
and an inpatient hospital stay provided from February 25, 2020 to March 24, 2020. 
 
You asked the Plan to waive the cost share for infusion drugs, an emergency room visit, and an inpatient 
hospital stay. You say that the cost share you are being charged is incorrect. The Plan denied your request. The 
Plan says the cost share you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for in-network Part B drugs, including chemotherapy drugs. Your contract with the Plan also 
clearly says that you must pay a $90 copayment per visit for emergency care. Your contract with the Plan also 
clearly says that you must pay a $210 copayment per day for days 1-6 per admission for in-network inpatient 
hospital care. 
 
You have been asked to pay $1161.05 ($5805.26 allowed x 20% coinsurance = $1161.05) for date of service 
February 25, 2020 and $806.43 ($4032.15 x 20% coinsurance = $806.43) for date of service March 10, 2020 
for infusion drugs. Infusion drugs fall within the Medicare Part B prescription drugs benefit category.  
 
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls 
within the emergency care benefit category. 
 
You have been asked to pay $1260 for your inpatient hospital stay (6 days x $210 copayment per day = $1260). 
An inpatient hospital stay falls within the inpatient hospital care benefit category. 
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for infusion drugs, an emergency room visit, and an inpatient 
hospital stay provided from February 25, 2020 to March 24, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on December 20, 2019. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you think you are being wrongly 
charged for this. 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 $10 
copayment for [Enter category in plan contract from outpatient diagnostic tests/ultrasounds.  
 
You have been asked to pay a $10 copayment for an ultrasound. The correct copayment has been applied to the 
services that were provided. An ultrasound falls within the outpatient diagnostic tests/ultrasounds 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 ultrasound provided by a participating 
provider on December 20, 2019