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

 
We decided that the Plan does not have to pay for the inpatient care provided from October 11, 2021, to 
October 15, 2021. 
 
You asked the Plan to pay for the inpatient care. You say that the enrollee was not enrolled in hospice on the 
dates of service in this case. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to 
verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on October 11, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient care 
provided from October 11, 2021, to October 15, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided on 
November 17, 2021. 
 
You asked the Plan to waive the copayment for the outpatient hospital visit. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
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 $100 
copayment for Outpatient hospital services.  
 
 
  You have been asked to pay a $100 copayment for an outpatient hospital visit. 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 visit provided on November 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a loop recorder for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the enrollee has not had any syncopal episodes and has not used an external 
heart monitor. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. While the patient has 
a history of atrial fibrillation/flutter, there is no documentation provided to suggest a history of unexplained 
syncope, cryptogenic stroke or any other apparent indication for an implantable loop recorder (ILR). In 
summary, there is insufficient documentation to support the medical necessity for insertion of an ILR in this 
patients clinical management. Our physician reviewer found that the enrollee's condition does not meet criteria 
for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a loop recorder for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient 
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient 
hospital care does not meet criteria. 
 
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 does not support that the criteria for inpatient hospital care are met in this 
case. Our physician reviewer found the health plan has approved the elective procedure left total shoulder 
arthroplasty. This is a request for inpatient services following this procedure. The documented preoperative 
clearance and comorbid conditions suggest that the procedure could initially be performed on an 
ambulatory/observation basis. There is no suggestion that the enrollee was unstable or that she might need 
hospital services that would likely cross 2 midnights associated with this procedure. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 9, 2021. 
 
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 testing is not covered. 
 The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, fluorescence in situ hybridization (FISH) testing, 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 July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an endocrinology office visit provided on 
November 1, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that you have never had a copayment 
before. The Plan denied your request. The Plan says the copayment amount you are being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 
copayment for specialist visit.  
 
You have been asked to pay $45 copayment for specialist visit. Specialist 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 an endocrinology office visit provided on November 1, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extended skilled nursing facility (SNF) stay. 
 
You asked the Plan to pre-approve an extended SNF stay. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 4, 2021, 
to January 10, 2022. The Plan has covered 100 days of SNF care.  
 
 
  Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pre-approve an extended skilled nursing facility (SNF) stay.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the office visit (99214) provided on September 16, 2021. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that payment for this service is included in the global 
surgery package. 
 
The Plan must follow Medicare rules. Medicare rules say that visits by the same physician on the same day as a 
minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately 
identifiable service is also performed. 
 
We find that CPT code 99214-25 is supported in the medical record. Specifically, the medical records indicate 
that the enrollee received a full work up and discussion regarding her condition and treatment options. The 
records clearly indicate that the evaluation and management service provided was separate and distinct from 
the injection. Based on this information, we decided that Medicare rules for coverage of the office visit have 
been met. Therefore, we decided that the Plan has to pay for the office visit (99214) provided on September 16, 
2021.  
 
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 pre-approve a replacement alignable endoskeletal system (L5910). 
 
You asked the Plan to pre-approve an alignable endoskeletal system. You say that this is medically necessary. 
The Plan denied your request. The Plan says there is no evidence provided that the current alignable system 
would not be sufficient. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an alignable system. This equipment serves the same purpose as an alignable 
endoskeletal system. There is no evidence provided that this equipment would not still be able to serve your 
medical needs. Therefore, we decided that the Plan does not have to pre-approve a replacement alignable 
endoskeletal system (L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an orthopedic specialist office visit 
provided on October 4, 2021, and a knee x-ray provided on November 29, 2021. 
 You asked the Plan to waive the copayments for a specialist office visit and an x-ray. You say that you had met 
your maximum out-of-pocket (MOOP). 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 $25 
copayment for an in-network specialist office visit. The Plan contract also says that enrollees must pay a $25 
copayment for an in-network x-ray. The Plan contract also says that enrollees must pay a $3,000 maximum out-
of-pocket for the calendar year. 
 
The record shows that you had originally met your MOOP but due to providers submitting corrected claims for 
services that you had previously received, the cost share associated with those claims was removed. Therefore, 
that caused you to have out-of-pocket expenses on future claims. You have been asked to pay a $25 copayment 
for a specialist office visit on October 4, 2021. A specialist office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. You have also been asked to pay a $25 copayment 
for an x-ray on November 29, 2021. The record shows your MOOP was met during the processing of this 
claim. An x-ray falls within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayments for an orthopedic specialist office visit provided 
on October 4, 2021, and a knee x-ray provided on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown re-bonding (D2920) provided by an out-of-network 
provider on December 28, 2021. 
 
You asked the Plan to pay for a crown re-bonding. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the rendered dental service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 a crown 
re-bonding (D2920) provided by an out-of-network provider on December 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this item is medically reasonable and 
necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
therapeutic continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 2021. 
 
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 are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on May 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of the Intracept procedure in 
the setting of chronic low back pain have not been demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Detailed 
documentation is not evident regarding imaging evidence of Modic changes at all of the requested levels. In 
this case, there were/are multiple plausible pathologic sources of significant pain generation. Overall, 
documentation was/is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal 
vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
Documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as being 
medically necessary and/or reasonable at this time. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool or bench (E0245). 
 
You asked the Plan to pre-approve a tub stool or bench. You say that you would greatly benefit from being able 
to sit while showering because you fear a fall. The Plan denied your request. The Plan says the requested item 
is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve CT heart, without contrast material, with quantitative evaluation of 
coronary calcium. 
 
You asked the Plan to pre-approve CT heart, without contrast material, with quantitative evaluation of coronary 
calcium. The Plan denied your request. The Plan says that Medicare policies do not cover certain screening 
studies including Coronary Calcium Scoring. 
 
The Plan follows Medicare rules.  
 
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 CT heart, without contrast material, 
with quantitative evaluation of coronary calcium. Our reviewer says that approve CT heart, without contrast 
material, with quantitative evaluation of coronary calcium is medically necessary. Our physician reviewer 
found that you take Atorvastatin for hyperlipidemia, and you have had an abnormal cardiac stress echo.  As 
such you are symptomatic for CV symptoms and qualifies for the requested CT calcium scoring. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT heart, without contrast material, with quantitative evaluation of coronary 
calcium have been met. Therefore, we decided that the Plan has to pre-approve CT heart, without contrast 
material, with quantitative evaluation of coronary calcium.   
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for therapeutic repetitive transcranial 
magnetic stimulation (TMS) treatment provided from July 6, 2021, to August 5, 2021. 
 
You asked the Plan to reduce the copayment for TMS treatment. You say that you were under the impression 
that each visit would be a copayment of $10-$20, not $30. You also say that you stopped treatment because it 
was not working and were under the impression you had 23 visits remaining. 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 $30 
copayment for medical care in a specialty physicians office. 
 
 You have been asked to pay a $30 copayment for each TMS treatment from July 6, 2021, to August 5, 2021 
($30 copayment x 23 visits = $690). TMS treatment falls within the Physician/Practitioner Services, Including 
Doctors 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 reduce the copayment for therapeutic 
repetitive transcranial magnetic stimulation (TMS) treatment provided from July 6, 2021, to August 5, 2021.