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

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve a genicular nerve block. You say that the requested genicular nerve block is
medically necessary. The Plan denied your request. The Plan says the requested items/services are not
considered medically reasonable and necessary in this case.
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 genicular nerve block. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this enrollee presents with a history of chronic right knee pain. She is diagnosed with
right knee osteoarthritis, and records suggest that she is status post total knee replacement. She is status post
multiple previous right knee genicular radiofrequency ablation with reported significant improvement on a
sustained basis for 6 months or more. Under consideration is a request for right knee genicular knee
block/radiofrequency ablation. There is a lack of large volume, long-term peer-reviewed outcome studies to
support the use of these procedures for this enrollee as discussed above. Additionally, the submitted medical
records do not provide a pain or functional assessment relative to the right knee. No clinical right knee exam is
documented. Therefore, this request for right knee genicular nerve block/radiofrequency ablation is not
medically reasonable and necessary at this time.
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 genicular nerve block have not been met. Therefore, we decided that the Plan
does not have to pre-approve a genicular nerve block.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
February 27, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were under the
impression that the authorization from the hospital to the skilled nursing facility via ambulance would not have
a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 copayment per one-way trip for emergency ambulance services and non-emergency
ambulance services. For this date of service, you have been asked to pay the allowed amount of the claim
because this amount is less than the $300 copayment for the ambulance transport.
The enrollee has been asked to pay a $226.18 copayment for the ambulance transport. The ambulance transport
falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the ambulance transport provided on February 27, 2020.
Our decision is only about the February 27, 2020 service. If you have any questions about prior billing, please
contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual wheelchair provided on February 15, 2020.
You asked the Plan to pay for the manual wheelchair. You say that you needed the wheelchair because of an
injury. The Plan denied your request. The Plan says you did not request authorization for the wheelchair.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the
patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can
be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the
manual wheelchair.
We looked at this the file and Medicare rules. Your physician also ordered a walker, which means your
condition can be improved by a walker. The physician order is after the date of service. There is no home
assessment. Based on this information, we decided that Medicare rules for coverage of the manual wheelchair
have not been met. Therefore, we decided that the Plan does not have to pay for the manual wheelchair
provided on February 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
October 14, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were incapacitated
from anesthesia during your transfer to the emergency room. You say you do not remember having services
and believe the cost should be included in the outpatient facility cost and not an additional copayment. The
Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 per visit.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The medical record shows you were treated for respiratory
distress.
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 emergency room visit provided on October 14, 2019.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly
maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer
duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or
participate in an IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar
Spine (72148).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that The
MRI is not medically necessary. Our physician reviewer found there is no bowel or bladder incontinence, and
the patient has normal strength and negative straight leg raise testing. There is also no mention that the patient
has tried conservative treatment for back pain such as, NSAIDS, physical therapy, topicals, or heat/ice.
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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 7,
2019.
You asked the Plan to waive the copayment for the office visit. You submitted your bill for review. You say
that you shouldn't be liable. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" 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 office visit provided on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram and the ultrasound
provided on March 11, 2020.
You asked the Plan to waive the deductible for the mammogram and the ultrasound. You say that you should
not be responsible for this bill because you had services that you did not need. The Plan denied your request.
The Plan says you have been charged the correct cost sharing amount.
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 that applies towards each basic imaging service (e.g.,
general x-rays or ultrasound).
The mammogram and ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules
by clearly disclosing in the contract that there is a $750 deductible that applies towards each basic imaging
service (e.g., general x-rays or ultrasound). The medical record shows the mammogram and ultrasound were
performed due to asymmetry of the right breast found on a comparison mammogram.
This cost sharing is a contractual obligation that had not been met at the time the mammogram and the
ultrasound were received on March 11, 2020. Therefore, we decided that the Plan does not have to waive the
deductible for the mammogram and ultrasound provided on March 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ranibizumab injection provided on
April 1, 2020.
You asked the Plan to waive the coinsurance for the ranibizumab injection. You say that you were not informed
you would have 20% coinsurance. You say that you shouldn't have to pay. The Plan denied your request. The
Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $343.31, which is 20% of the allowed amount for the ranibizumab injection. The
allowed amount is $1,716.55 (20% x $1,716.55 = $343.31). The ranibizumab injection falls within the
"Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for
the ranibizumab injection provided on April 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 6, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not support a valid order for this test.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing radiographic images (D0274) provided on
December 18, 2019.
You asked the Plan to pay for the bitewing radiographic images. You say that you would like reconsideration
because you were not aware that this service would not be covered. The Plan denied your request. The Plan
says this service is not listed as covered in the Plan's EOC.
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 pay for bitewing
radiographic images (D0274) provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on January 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 5, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that if the bandage was wrapped properly
you wouldn't have went to the emergency room. You say that the copayment should be paid by the surgical
center. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120
copayment for emergency care.
You have been asked to pay a $120 copayment for the ER visit. The ER visit 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 the ER visit provided on March
5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist
device.
You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say
that this device would restore function to the dysfunctional arm and the ability to perform activities of daily
living. The Plan denied your request. The Plan says a review of the current medical literature indicates that this
device is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary, and are experimental and investigational, are not covered.
We looked at the file and Medicare rules. There is insufficient medical record information submitted to show
this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by
Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper
extremity range of motion assist device (L8702) have not been met. Therefore, we decided that the Plan does
not have to pre-approve a powered upper extremity range of motion assist device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on October 18, 2019.
You asked the Plan to pay for the drug testing. 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 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99231) provided on August 29, 2019.
You asked the Plan to pay for hospital care. You say that this service was not a duplicate. The Plan denied your
request. The Plan says payment for this service is included in the global surgery package.
The Plan must follow Medicare rules. Medicare rules say that post-operative services routinely performed by
the surgeon or by members of the same group with the same specialty are included in the global surgical
package.
We looked at the file and Medicare rules. The record shows that the enrollee had an ankle fracture treatment
(27810) on July 6, 2019. The global period for this service is 90 days. Based on this information, we decided
that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does
not have to pay for hospital care (99231) provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physician's services.
You asked the Plan to pre-approve the physician's services. You say that this physician understands your
condition any you do not want to start all over again with a different physician. The Plan denied your request.
The Plan says your plan requires you to receive care from providers who are part of your primary care
physician's (PCP) specialty network.
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 contract with
the Plan also says that your plan requires you to receive care from providers who are part of your primary care
physician's (PCP) specialty network.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite of one surface provided on
December 12, 2018.
You asked the Plan to pay for the resin-based composite of one surface. You say that you do not understand
how these services are not covered. The Plan denied your request. The Plan says your plan covers one white
filling every 3 years.
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, composite restorations are limited to
one procedure every three years. The record shows that you received two resin-based composites on December
12, 2018, one of which was covered by the Plan, and your composite restorations benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the resin-based composite of one surface provided
on December 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the specialist office visits provided from
January 29, 2019 to January 29, 2020.
You asked the Plan to reduce the copayments for the specialist office visits. You say that you do not this is
provider as an allergist, and you only see him as an internal medicine patient. You say you should only pay the
$10 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $35 copayment for each in-network covered specialist office visit.
The enrollee has been asked to pay a $35 copayment for each of the specialist office visits. The specialist office
visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The
record shows that the provider is not listed as a primary care physician.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to reduce the copayments for the specialist office visits provided from
January 29, 2019 to January 29, 2020.