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

 
We decided that the Plan does not have to waive the copayment and coinsurance for the specialist services and 
infliximab infusion provided on January 11, 2022. 
 
You asked the Plan to waive the copayment and coinsurance for the specialist services and infusion. You say 
that when you switched plans you were under the impression that these costs would be alleviated. The Plan 
denied your request. The Plan says the correct copayment and coinsurance were 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 $35 
copayment for each specialist visit. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for each Part B drug. 
 You have been asked to pay a $35 copayment for the specialist services. The specialist services fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $0.13 for the saline infusion, which is 20% of the allowed amount ($0.65 allowed amount x 20% 
coinsurance = $0.13), and $316.24 for the infliximab infusion, which is also 20% of the allowed amount 
($1,581.20 x 20% coinsurance = $316.24). The infusion falls within the Medicare Part B Prescription Drugs 
benefit category. The total for the services is $351.37. 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 and 
coinsurance for the specialist services and infliximab infusion provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network (OON) annual wellness 
visit provided on January 10, 2022. 
 
You asked the Plan to waive the coinsurance for the OON wellness visit. You say that wellness visits should be 
covered 100%. The Plan denied your request. The Plan says the correct coinsurance was 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 40% 
coinsurance for an annual wellness visit with an out-of-network provider.  
 
You have been asked to pay $61.54, which is 40% of the allowed amount for the OON wellness visit ($153.86 
allowed amount x 40% coinsurance = $61.54). The OON wellness visit falls within the Annual Wellness Visit 
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 an out-of-network (OON) 
annual wellness visit provided on January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound care services provided on February 
14, 2022, and February 21, 2022. 
 
You asked the Plan to waive the copayments for the wound care. You say that the claims were coded 
incorrectly for billing. 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 $165 
copayment for ambulatory surgical center or outpatient hospital facility admissions.  
 
You have been asked to pay a $165 copayment for each wound care visit, for a total of $330. The wound care 
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 copayments for wound care 
services provided on February 14, 2022, and February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this shower chair is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or 
the Plan. 
 
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 shower chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health services provided from February 28, 2022, to 
March 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they were 
non-emergent and prior authorization was not obtained. 
 
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 had network providers 
available who could have provided 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 mental health services provided from February 28, 
2022, to March 3, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot 
orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested ventilator is medically 
necessary. The Plan denied your request. The Plan says the requested ventilator does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found you have chronic respiratory failure 
from chronic obstructive pulmonary disease. The provided primary source documentation does not contain 
sufficient detailed information in the medical record to justify the treatment selected. You could be treated with 
a BiPAP machine with AVAPS capability. The plan has indicated such a device is covered. The elements of 
the coverage criteria are not satisfied. 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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
You asked the Plan to pre-approve the SNF care. You say that you are requesting a SNF stay following a 
hospitalization for fatigue and failure to thrive. The Plan denied your request. The Plan says the available 
records do not indicate ongoing daily skilled needs and the enrollee's ongoing needs are largely custodial in 
nature.  
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 the SNF care. Our reviewer says that 
the SNF care is not medically necessary. Our physician reviewer found the based on the documentation 
provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not 
have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance 
program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a 
practical matter, be provided at a lower level of care (ex. home with services, long-term 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for GeneSight Psychotropic pharmacogenomic test (81479) 
provided July 13, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that GeneSight Psychotropic has significant 
clinically utility and has proven to be a predictor of a patient's overall health outcome success. The Plan denied 
your request. The Plan says this service does not meet the Medicare criteria. 
 
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 pay for the laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this comprehensive gene test includes many genes not applicable to this enrollee's 
prescribing physician's plan which is to consider adding either Effexor or Zoloft. There was no documentation 
suggesting any other drugs or classes were being considered to have any genes tested beyond those that were 
applicable to this specific decision. Therefore, this test appears to be excessive for this enrollee and will be 
considered not medically necessary based on the provided documentation. 
 
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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for GeneSight Psychotropic pharmacogenomic test (81479) provided July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee still requires acute care services before 
transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not 
been denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH facility. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition to lower extremity prosthesis, endoskeletal, 
knee disarticulation, above knee, hip disarticulation, positional rotation unit (K1022). 
 
You asked the Plan to pre-approve a positional rotation unit. You say that the rotational adapter is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the request for a rotational unit exceeds 
the enrollee's need and does not meet Medicare criteria as reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve positional rotation unit. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee reported pain and discomfort throughout her limb, making it difficult for 
her to stand for long periods of time and walk long distances without significant pain. The enrollee was eager 
to receive a new socket that is more comfortable. The case file does not contain sufficient clinical 
documentation supporting the medical need for the requested unit. 
 
 We looked at this physician's review, the file, and Medicare rules. Please note, that all other sockets and 
components were approved. Based on this information, we decided that Medicare rules for coverage of 
positional rotation unit have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, 
positional rotation unit (K1022).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services on April 12, 2021. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you would like to appeal the 
cost share. The Plan denied your request. The Plan says the copayment applied 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 a $65 
copayment for urgent care services.  
 
You have been asked to pay a $65 copayment for urgent care services. Urgent care services falls within the 
urgently needed 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 urgent care 
services on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient hospital admission for BaroStim Neo System 
Implant (0266T, C1825). 
 
You asked the Plan to pre-approve BaroStim Neo System Implant. You say that the enrollee's medical record 
supports the medical necessity of the BaroStim Neo System implant. The Plan denied your request. The Plan 
says the requested BaroStim Neo System Implant and associated inpatient hospital admission is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve BaroStim Neo System Implant. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in August 2019 the FDA approved the BaroStim Neo system for use in 
patients with refractory heart failure who remain symptomatic despite treatment with guideline-directed 
medical therapy, are NYHA Class III, have an ejection fraction less than 35%, and are not candidates for bi-
ventricular pacing. This was based on a clinical study demonstrating improvement in normal daily activities, 
distance walked, quality of life, and improved cardiac levels biomarker levels. There remains an absence of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of BaroStim 
Neo in patient management. As a result, at this time the BaroStim Neo system would not be considered 
medically reasonable and necessary in this patient's clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BaroStim Neo System Implant have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient hospital admission for BaroStim Neo System Implant (0266T, 
C1825).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested device is only covered if 
the enrollee in enrolled in a clinical trial. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found The CardioMEMS device was approved by the Food and Drug Administration 
(FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of 
pulmonary artery pressure in the management of patients with congestive heart failure. The clinical study on 
which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients 
in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection 
fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an 
improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS.  Nonetheless, there remains a 
dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
February 10, 2022. 
 
You asked the Plan to waive the copayment for the ECG. You say that this service was always covered in the 
past. 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 non-radiological diagnostic services.  
 
You have been asked to pay $18.60, which is less than the $25 copayment for the ECG. The ECG 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 copayment for an electrocardiogram (ECG) provided on February 10, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services on February 7, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the copayment applied 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 a $50 
copayment for emergency room services.  
 
You have been asked to pay a $50 copayment for emergency room services. Emergency room services 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 emergency 
room services on February 7, 2022.