Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveinpatient hospital care beginning on October 6, 2020.You asked the Plan to pre-approveacute inpatient hospital care. You say that the services are necessary.The Plan denied your request. The Plan says that the criteria have not been met for inpatient hospital care, but observation level of care is approved.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records demonstrate that the enrollee had ongoing symptoms of dizziness upon standing that were not resolved within day one of hospitalization despite some treatment with intravenous (IV) fluids. It is medically appropriate for ongoing inpatient hospital care for evaluation and treatment beyond one inpatient night for an individual of this age with very high risk of fall and morbidity.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pre-approveinpatient hospital care beginning on October 6, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care (99309) provided on April 29, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says services rendered by out-of-network providers must 
obtain 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 nursing facility care (99309) provided on April 
29, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the care can be received in another setting, such as home, a long-term care facility, 
or other outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
setting 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar epidural steroid injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no evidence provided of a failure of four or more weeks of non-surgical, 
non-injection care. 
 
 
 
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 injections. Our reviewer says that 
the requested injections are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of a failure of at least four weeks of non-surgical, non-injection care. 
Exceptions to waiting 4 weeks since the onset of pain before receiving an LESI exist, but circumstances should 
be clearly documented in the medical record, which was not done in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar epidural steroid injections for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for specialist services and 
medical supplies provided by a participating provider on February 6, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for specialist services and medical supplies. You 
say that this should be part of the 90-day global period. The Plan denied your request. The Plan says the correct 
copayment and coinsurance have 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 $45 
copayment for outpatient diagnostic tests/in-network/provider services/specialist and a 20% coinsurance for 
outpatient diagnostic tests/in-network/medical supplies.  
 
You have been asked to pay a $45 copayment for specialist services and a 20% coinsurance of the allowed 
amount for medical supplies. The total allowed amount is $42.77. The total amount you are being asked to pay 
for medical supplies is $8.55 ($42.77 x 20% = $8.55). The total amount you are being asked to pay is $53.55 
($45 + $8.55 = $53.55). Specialist services fall within the outpatient diagnostic tests/in-network/provider 
services/specialist benefit category and medical supplies falls within the outpatient diagnostic tests/in-
network/medical 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 copayment for specialist 
services and coinsurance for medical supplies provided by a participating provider on February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the colonoscopy with polyp removal you 
had on March 10, 2020. 
 
You asked the Plan to waive the copayment for the colonoscopy with polyp removal. You say that you have 
not had to pay this copayment when you have had colonoscopies in the past. The Plan denied your request. The 
Plan says you were charged this copayment correctly because polyps were removed during the colonoscopy. 
 
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 $150 
copayment for outpatient surgery services.  
 
Your Evidence of Coverage states that if you have lesions or growths removed during a colonoscopy, it is 
considered a diagnostic colonoscopy and the copayment for outpatient surgery applies.  In this case, you had 
polyps removed during your colonoscopy. You have been asked to pay a $150 copayment for the colonoscopy 
with polyp removal. The colonoscopy with polyp removal falls within the outpatient surgery 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 colonoscopy with polyp removal you had 
on March 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a 
participating provider on March 12, 2020. 
 
You asked the Plan to waive the copayment for an ambulance trip. You say that the ambulance took you from 
one end of the building to the other end. You say that you were not allowed to walk. 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 $225 
copayment for ambulance services/ground transportation.  
 
You have been asked to pay a $225 copayment for an ambulance trip. Since an ambulance trip was provided; 
the correct copayment has been applied. An ambulance trip falls within the ambulance services/ground 
transportation 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 ambulance trip provided 
by a participating provider on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a blood pressure cuff for home blood pressure monitoring. 
 
You asked the Plan to pay for blood pressure cuff. You say that because of COVID-19 you are unable to get to 
a store or clinic to have your blood pressure taken. The Plan denied your request. The Plan says the denial of 
payment for this item is correct, because this item is not covered and was purchased from an out-of-network 
retail pharmacy which is not a durable medical equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pay for a blood pressure cuff for home blood pressure 
monitoring.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network services provided on October 19, 2019.You asked the Plan to pay forthis service. You say that this visit should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 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 forout of network services provided by on October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
anticoagulation therapy is contraindicated. 
 
 
 
The Plan follows Medicare rules. Medicare rules say that lumbar epidural steroid injections are only covered 
under certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has a diagnosis of chronic low back pain with severe multilevel lumbar spinal 
stenosis with neurogenic claudication and left L3-L4 radiculopathy. The enrollees significant past medical 
history includes cerebrovascular accident with right sided weakness and carotid occlusion on Plavix. Based 
upon the submitted documentation, lumbar epidural steroid injection is contraindicated in this enrollee. He has 
a co-existing medical condition that precludes the safe performance of the procedure, e.g., uncontrolled 
coagulopathy or active anti-coagulation therapy.  Therefore, the requested lumbar epidural steroid injection is 
not medically reasonable and necessary for the enrollee's condition. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan doesnot have to pay forthe root canal (D3330) provided on June 2, 2020.You asked the Plan to pay forthe dental service. You say that you have a permanent bridge on tooth # 3. You say that the root canal was necessary. You say that you thought the Plan covered $1,000 worth of dental services. You also say that you did not realize that there were exclusions.The Plan denied your request. The Plan says root canal is not listed as a covered service. The Plan also says any services not listed are not covered.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 forthe root canal (D3330) provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician office services provided on April 21, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for physician office services. You say that you have a referral for this visit. The Plan 
denied your request. The Plan says they did not receive a primary care physician referral to review and approve 
prior to the out-of-network provider services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physician office services provided on April 21, 
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hearing services provided by a non-
participating provider on January 27, 2020. 
 
You asked the Plan to waive the copayment for hearing services. You say that you would like to know why 
there are these charges since the Plan said they have already been paid. 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 $70 
copayment for hearing services/out-of-network.  
 
You have been asked to pay $54.45 which is less than your copayment amount of $70 for hearing services. 
Hearing services fall within the hearing services/out-of-network 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 hearing services provided by a non-participating provider on January 27, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the outpatient therapy services provided to a long-term care resident from December 2, 2019 to December 31, 2019.

You asked the Plan to pay for the outpatient SNF therapy. You say that this was correctly billed for Part B covered SNF therapy which does not require prior authorization according to the Plan website. The Plan denied your request. The Plan says that this was not validly billed as CRU mentioned.

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. In this case, the Plan has not provided any sort of cogent denial rationale. The Plan denied the claim for no authorization but it is noted that authorization is not required for Part B skilled nursing facility services. Furthermore, the Plan did not endorse this claim denial rationale on appeal and instead has indicated that "Payment is not allowed for this service because it is not billed with valid billing therapy services as 'CRU Mentioned'". Researched this term and reviewed the claim. We could not verify the meaning nor find any blatant errors on the face of the claim to support invalid billing. Since the Plan has not referenced any specific and verifiable error on the claim, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to pay for the outpatient therapy services provided to a long-term care resident from December 2, 2019 to December 31, 2019. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on March 20, 2020.

You asked the Plan to waive the copayment for the medical eye exam. You say that this visit should be coded as a routine eye exam.  You stated that the mere fact that you had cataract surgery years ago shouldn't preclude your ability to have a routine eye exam and not be charged a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for medical eye exams. 

You have been asked to pay a $20 copayment for the ophthalmology visit. We looked at the medical records in this case. For this date of service, the medical records indicate that this was a medical, not a routine, eye exam.  Specifically, the records show that the doctor reviewed your symptoms of eye floaters, which were stable.  In addition, your doctor did note that you had a history of cataract surgery but that you are happy with your current prescription and you were not suffering from dryness or flashes. You also completed and updated medical history questionnaire during this visit. Because of these factors, the exam falls within the medical eye exams 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 medical eye exam you had on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360? molecular pathology testing provided. 
 
You asked the Plan to pay for the Guardant360? testing. You say that you would like reconsideration because 
all of the member's available treatment options require molecular testing to determine eligibility. The Plan 
denied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360? molecular 
pathology genomic profiling for prostate cancer, and the appropriate DEX Z-Code? identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that to report CGP testing, test providers should use 
CPT code 81479. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360? testing have not been met. Specifically, this claim has not been billed with the 
appropriate CPT code. CPT code 81479 is used to report CGP testing at this time. Therefore, we decided that 
the Plan does not have to pay for Guardant360? molecular pathology testing.