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

 
We decided that the Plan does not have to waive the copayment for the hospitalist Nurse Practitioner visit you 
had on July 20, 2020. 
 
You asked the Plan to waive the copayment for the hospitalist Nurse Practitioner visit. You say that you 
already paid a copayment for the procedure you had, and you do not think you should have to pay a separate 
copayment for this visit. The Plan denied your request. The Plan says this copayment was appropriately 
charged for the preoperative visit you had. 
 
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 specialist visits.  
 
You have been asked to pay a $35 copayment for the hospitalist Nurse Practitioner visit. The hospitalist Nurse 
Practitioner visit falls within the specialist visits benefit category. Plans are permitted to charge copayments for 
preoperative specialist visits. 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 hospitalist Nurse 
Practitioner visit you had on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213-GT) and psychotherapy (90833-GT) 
provided from April 30, 2020, to August 20, 2020. 
 
You asked the Plan to pay for an office visit and psychotherapy. You say that this should be covered. The Plan 
denied your request. The Plan says this was billed with an incorrect modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
requirement to use the GT modifier has been eliminated. 
 
We find that this claim is not supported as billed. Modifier GT is no longer used for telehealth services. Based 
on this information, we decided that Medicare rules for coverage of an office visit and psychotherapy have not 
been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213-GT) and 
psychotherapy (90833-GT) provided from April 30, 2020, to August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on June 5, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. The Plan denied your request. The Plan says the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 outpatient hospital services provided on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 4, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the enrollee has to be seen regardless of referral or prior 
authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee self-directed for service. 
 
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 medical services provided on May 4, 2020 by 
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Custom Radial Gutter Thumb Spica Splint 
provided on July 1, 2020, by an in-network provider. 
 
You asked the Plan to waive the coinsurance for the splint. You say that this was a post-operative visit and 
everything should be covered. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file show that you received the Custom Radial Gutter 
Thumb Spica Splint on July 1, 2020, by an in-network provider. You are asked to pay 20% coinsurance for the 
splint. Your EOC states that enrollees must pay 20% for in-network Medicare-covered equipment and supplies. 
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 Custom Radial Gutter Thumb Spica Splint provided on 
July 1, 2020, by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0481) provided June 3, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 code G0481 is not supported in the medical record. Specifically, no clinical progress notes 
were provided. Without this information, medical necessity cannot be determined. Based on this information, 
we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services (G0481) provided June 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (77003, J3301, J2001) provided July 15, 
2020. 
 
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says rules for coverage were not met. 
 
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 code 77003, J3301, J2001 is not supported in the medical record. Specifically, the primary 
code was not covered, therefore the associated code cannot be approved. The claim also included an invalid 
National Drug Code (NDC). Bundled services cannot be separately paid. Based on this information, we 
decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that 
the Plan does not have to pay for surgical services (77003, J3301, J2001) provided July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS HF system. 
 
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF 
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
system is not medically necessary. 
 
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 a CardioMEMS HF system. Our 
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer 
found the enrollee is with NYHA Class III congestive heart failure with preserved LV ejection fraction (LVEF 
60%) requiring hospital admission. A request was made for placement of a CardioMEMs device. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one randomized prospective 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 according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not 
met since the 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 a CardioMEMS HF system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 22, 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be 
billed with the most precise diagnosis code. 
 
We looked at the file and Medicare rules. The file shows that the claim was not billed with an appropriate 
primary diagnosis code. 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 emergency room 
(ER) services rendered on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 17, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 17, 2020 by 
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for the services provided from March 16, 
2020, through July 20, 2020. 
 
You asked the Plan to waive the cost-sharing for the services. You say that you should not be assessed a 
coinsurance for the equipment and services you received because you were unaware this equipment was 
covered with a 20% coinsurance. The Plan denied your request. The Plan says the claims were processed 
accordingly with your 2020 EOC benefits. 
 
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The Plan's records 
show that the materials you received on the above dates were equipment and supplies for home enteral nutrition 
infusion, which are covered under your policy?s prosthetic devices. The health plan contract says that enrollees 
must pay 20% coinsurance for devices (other than dental) that replace all or part of a body part or function. 
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-sharing for the services provided from March 16, 2020, through July 
20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says that the enrollee requires continued care in the 
acute care setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
appears to be more stable but recent GI bleed and ventilation needs requires additional short term acute care 
services to allow for weaning and resolution of the gastrointestinal bleed which can be safely completed in the 
current setting. It is not yet clear if the patient is able to be weaned or not as weaning has not yet been tried. 
The patient does not require services at the LTACH that are not already available at the current facility. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on June 15, 2020. 
 
You asked the Plan to pay for the oxygen concentrator. You say that you would like reconsideration because 
this equipment rents for 36 continuous months. The Plan denied your request. The Plan says the provider has 
met the max of 36 months. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code E1390 is not supported in the record. Specifically, Medicare pays no more than 36 
continuous monthly rental payment amounts for oxygen and oxygen equipment. The record indicates that the 
Plan has paid for 36 months. Based on this information, we decided that Medicare rules for coverage of the 
oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the 
oxygen concentrator (E1390) provided on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305, 88312) provided on July 9, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for OON laboratory services. You say that this should not be considered out-of-
network. The Plan denied your request. The Plan says this was 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 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 laboratory services (88305, 88312) provided 
on July 9, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiography. 
 
You asked the Plan to pre-approve a transthoracic echocardiography. You say that the requested transthoracic 
echocardiography is medically necessary. The Plan denied your request. The Plan says that the requested 
transthoracic echocardiography is not medically necessary. 
 
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 a transthoracic echocardiography. Our 
reviewer says that the requested transthoracic echocardiography is medically necessary. Our physician reviewer 
found the enrollee has significant symptomatic ongoing pericarditis and a pericardial effusion without prior 
evidence of tamponade. She has continued chest symptoms and has been intolerant of most treatment regimens. 
A repeat limited echocardiography study to reassess the size of the effusion and any early signs of tamponade 
one month since the last study is reasonable and medically necessary and conforms to CMS criteria for 
frequency of the study in this clinical instance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transthoracic echocardiography have been met. Therefore, we decided that the 
Plan has to pre-approve a transthoracic echocardiography.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis (L3809 RT, LT) provided December 11, 2019. You asked the Plan to pay for the orthoses. You say that attached are the requested medical records.  The Plan denied your request. The Plan says the records do not support the service 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. The record does not contain a valid itemized shipping/billing invoice or the proof of delivery to indicate the specific supplies. 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 the wrist hand finger orthosis (L3809 RT, LT) provided December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 6, 2020 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 6, 2020
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for over the counter supplies purchased on September 13, 2020, through 
September 17, 2020. 
 
You asked the Plan to pay for the over the counter supplies. You say that you would like reconsideration 
because you need natural cold remedies and masks to prevent the spread of COVID-19. The Plan denied your 
request. The Plan says that this benefit has been exhausted. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has failed to forward evidence that this benefit has been 
exhausted. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is 
not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for over the 
counter supplies purchased on September 13, 2020, through September 17, 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.