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

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided 
on March 5, 2021. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you thought 
that you would only owe a $25 copayment because you did not receive any kind of surgical services. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
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 $150 
copayment for each non-surgical visit to an outpatient hospital department. 
 
The record shows that you had an outpatient hospital facility visit on March 5, 2021. Therefore, you are 
responsible to pay the allowed amount of $111.09, which is less than the $150 copayment.   
 You have been asked to pay $111.09 for an outpatient hospital facility visit. An outpatient hospital facility visit 
falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient hospital 
facility visit provided on March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystourethroscopy with transprostatic 
implant procedure you had at an outpatient hospital facility from May 24, 2021, to May 26, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that your doctor recommended 
this procedure so that you could stop taking Flomax.  Following surgery, you still need to take this medication, 
so you don't think you should be responsible for this charge. 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 $325 
copayment for outpatient surgery at an outpatient hospital facility.  
 
You have been asked to pay a $325 copayment for the outpatient surgery. This copayment applies regardless of the outcome of the procedure. 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 cystourethroscopy with 
transprostatic implant procedure you had at an outpatient hospital facility from May 24, 2021, to May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve below knee prosthesis, additions, and accessories 
identified with codes L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5685, L5704, L5910, L5940, 
L8420, L8440, L8470, L5962, L5973, and L5781 
 
You asked the Plan to pre-approve below knee prosthesis, additions, and accessories. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that below knee prosthesis, additions, and accessories are 
only covered for certain 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 below knee prosthesis, additions, and 
accessories. Our reviewer says that the documentation does not support that the requested items are medically 
reasonable or necessary. Our physician reviewer found the enrollee a diagnosis of acquired absence of the right 
leg below the knee secondary to complications from diabetes mellitus and peripheral vascular disease. The 
enrollee underwent a right below the knee amputation (BKA) on June 20, 2021 followed by a subsequent 
revision right BKA on July 28, 2021. The enrollee is a new amputee and has never worn a prosthesis. The 
progress notes state that the enrollee underwent a revision right BKA, incision and drainage with complex 
wound closure, the wound is improving and has an area of wound gaping with fibrinous tissue, mild serous 
drainage and a recommendation is made to continue dressing changes. The sutures were removed at the visit. 
The progress note shows that the wound has not finished healing. The prosthetic evaluation and prescription 
dated July 21, 2021 states that the enrollee currently requires assistance for feeding, eating, transferring, 
mobility and needs major assistance for transportation, shopping, and completing housework. The 
documentation does not reveal that the enrollee's wound is fully healed on the residual limb, that the enrollee has tried a preparatory prosthesis yet,  or that the enrollee is a K3 ambulator. Therefore, the enrollee does not 
meet criteria for the requested items 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 below knee prosthesis, additions, and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve below knee prosthesis, additions, and accessories 
identified with codes L5301, L5620, L5629, L5637, L5645, L5647, L5679, L5685, L5704, L5910, L5940, 
L8420, L8440, L8470, L5962, L5973, and L5781
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you have dementia and 
sun downer's syndrome. You say that you are unable to care for yourself and it would be unsafe to discharge 
you. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says 
that the records do not show that the enrollee is a threat to himself or others. The Plan says that the enrollee 
requires custodial care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 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 inpatient psychiatric hospital services. 
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found you were 
admitted to the acute inpatient psychiatric hospitalization on November 20, 2021, with Major Neurocognitive 
most likely due to Vascular Illness without Behavioral Disturbance. Based upon review the records provided it 
was not expected you would improve in a reasonable period of time as you did not have dangerousness to self 
or others, auditory or visual hallucinations, delusions and were not showing any aggressive behavioral issues. It 
did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level 
of care rather than a lower level of care as you did not have dangerousness to self or others, perceptual 
disturbance including auditory or visual hallucinations. You did not appear to require inpatient mental health 
treatment as you were not a danger to yourself or others and were cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show that the enrollee needs daily therapy or nursing services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that the procedure is to 
remove bone that sticks out into your teeth. You say that the procedure is necessary to be able to have dentures. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
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 the 
removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99212) rendered on May 4, 
2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the reason you signed up for this 
plan was because you were told the provider in question would be your primary care physician (PCP) and you 
would not have to pay any copayments for your visits to this provider. The Plan denied your request. The Plan 
says you were charged the correct copayment 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 $40 
copayment for each Medicare-covered out-of-network primary care doctor office visit.  
 
You have been asked to pay a $40 copayment for an office visit. The records show this provider is not in-
network. 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 office visit (99212) rendered on May 4, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from August 17, 2020, to August 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were served 
undercooked chicken and, as a result, had to stay in the hospital one extra day. 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 $295 
copayment per day for days 1-6 for inpatient hospital services. 
 
Records show that you were in the hospital for 3 days.  You were charged a copayment of $295 for each day, 
for a total of $885. This copayment applies regardless of your satisfaction with the services or the reason for 
the length of your stay. 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 inpatient hospital services you 
received from August 17, 2020, to August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve a wheelchair ramp. You say that you cannot enter home without this item. 
The Plan denied your request. The Plan says This item is not medical in nature and it is not used in the home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 25, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.

We find that CPT code 97530 is not supported in the record. Specifically, this claim was billed by a nurse practitioner. There is no evidence that the nurse practitioner was present in the home to provide direct supervision while the services of the occupational therapist were rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the debridement of subcutaneous tissue 
(11042, G0463) rendered from March 15, 2021, to April 12, 2021. 
 
You asked the Plan to waive the copayment for the debridement of subcutaneous tissue. You say that you never 
pay a fee for this service, just the copayment for an office visit. You also say you do not agree with paying this 
bill for the provider to clean and bandage with a gauze pad on a weekly basis, and someone is over charging. 
The Plan denied your request. The Plan says you were charged the correct copayment 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 $250 
copayment per visit for outpatient surgery or procedure at a hospital facility.  
 
 You have been asked to pay a $250 copayment per visit for two visits of the debridement of subcutaneous 
tissue from March 15, 2021, to April 12, 2021, which is a total of $500 ($250 x 2 = $500). The debridement of 
subcutaneous tissue falls within the Outpatient Surgery, including services Provided at Hospital Outpatient 
Facilities and Ambulatory Surgical Centers 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 debridement of subcutaneous tissue (11042, G0463) rendered from March 15, 2021, to April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing coded 81479 provided on March 16, 2021.

You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 81479 is not supported in the medical record. Specifically, the claim did not include the requires Z code identifier. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing coded 81479 provided on March 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on April 30, 
2020. 
 
You asked the Plan to pay for the therapeutic exercises. You say that you would like this claim to be 
reprocessed towards payment. The Plan denied your request. The Plan says Original Medicare would be 
responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal 
condition. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 23, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the lab services provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and 
supplies. 
 
You asked the Plan to pre-approve a Freestyle Libre and supplies. You say that the requested item is a 
necessity for the enrollee's care. The Plan denied your request. The Plan says rules for coverage for durable 
medical equipment have not been met. 
 
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 physician order for the supplies requested in this case. 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 pre-approve a Freestyle Libre continuous glucose monitor and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226).

You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says this service is 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 pre-approve a mandibular partial denture (D5226).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C. 
 
You asked the Plan to pre-approve Gamunex-C. The Plan denied your request. The Plan says this medication 
does not fall under Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Gamunex-C.  
 
Benefits for Gamunex-C may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complicated suture (D7911) and two bone 
replacement grafts for ridge preservation (D7953 x2). 
 
You asked the Plan to pre-approve the complicated suture and bone replacement grafts. You say that you need 
these services to be done, but they are being denied. 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 
complicated suture (D7911) and two bone replacement grafts for ridge preservation (D7953 x2).