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

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on 
June 27, 2022 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be 
covered as you disagree with the denial. 
 The Plan denied your request. The Plan says this cost sharing was charged 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 $45 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
 
  You have been asked to pay a $45 copayment for the specialist office visit. This item/service 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 a specialist office visit (99213) provided on June 27, 2022
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse an additional amount for Covid-19 testing (U0004, 
U0005) provided on January 14, 2022. 
 
You asked the Plan to reimburse an additional amount for Covid-19 testing. You say that the insurance must 
reimburse the non-contracted provider in an amount that equals the cash price for such services listed by the 
provider on a public internet website. Requesting claim be reprocessed to pay a total of $250.00. The Plan 
denied your request. The Plan says must accept Medicare rates for the COVID test. CMS rule dictates 
providers that participate with Medicare must accept the Medicare reimbursement as payment in full. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non-
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee.  
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Covid-19 testing have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to reimburse an additional amount for 
Covid-19 testing (U0004, U0005) provided on January 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool (E0245). 
 
You asked the Plan to pre-approve a tub stool. You say that you suffer from dizziness, and you tend to fall 
frequently. You also say you live alone and when you fall, you will not have anyone to help you get up. You 
are currently taking medication, but you are still not 100% better. The Plan denied your request. The Plan says 
the requested tub stool does not meet the definition and therefore is not a covered under Medicare. 
 
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 tub stool (E0245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertilfex device is experimental. More research is needed. 
 
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 Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sclerotherapy (36471) and phlebectomy (37765). 
 
You asked the Plan to pre-approve sclerotherapy and phlebectomy. You say that you disagree with the denial. 
The Plan denied your request. The Plan says you are requesting the above procedures to treat your symptomatic 
tributary veins in your legs. However, documentation indicates there is current saphenous reflux; therefore, the 
criteria listed above have not been met and these procedures cannot be approved at this time. 
 
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 sclerotherapy and phlebectomy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the documentation does not meet coverage criteria and does not support the 
medical necessity of the procedures in question. Coverage criteria require that for tributary treatment to be 
considered medically necessary, the saphenous reflux has to be treated first.  If following saphenous vein 
treatment, the enrollee has persistent lifestyle limiting symptoms despite 6 weeks of conservative treatment in 
the absence of saphenous reflux, tributary treatment may be considered.  The health plan has approved the 
saphenous reflux treatment. The health plan does not provide for simultaneous treatment of the saphenous 
reflux and tributary veins. A rationale for this is that many patients will experience satisfactory improvement 
with saphenous treatment alone, and the additional treatments may be rendered unnecessary. There are no 
unique features of this enrollee's condition that would provide a medically necessary reason to override this 
policy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sclerotherapy and phlebectomy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve sclerotherapy (36471) and phlebectomy (37765).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was residing in the skilled nursing facility at a custodial level of care 
when they were diagnosed with COVID-19 infection. There is no documentation to support that the enrollee 
required any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. Admission at 
the skilled level of care is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of v have not been met. Therefore, we decided that the Plan does not have to pre-
approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on May 31, 2022. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary and should be 
paid. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on May 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have a standard post-acute functional impairment routinely managed at a 
variety of levels and does not require admission to an IRF per clinical practice and evidence-based standards.  
 You have stable chronic medical conditions managed at an outpatient level. There is no indication for frequent 
physiatry oversight. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for neuromuscular junction testing (repetitive stimulation, paired stimuli), 
each nerve, any 1 method provided to the enrollee on June 28, 2022. 
 
You asked the Plan to pay for the services. You say that the services were reported correctly. The Plan denied 
your request. The Plan says that the records do not support the services 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. In this case, the CPT Code Manual definition of 
code 95937 is "Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 
method." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case are supported by the medical records. Our reviewer found that procedure code 95937 is supported by 
the documentation, as the description of the procedure is clearly stated in the summary of the medical records. 
It states that the electrocardiogram and symmetrical throughout the procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method provided to 
the enrollee on June 28, 2022.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says we do not have the information we need to consider 
this charge. 
 
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 laboratory services provided on May 12, 2022, by 
an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

 
We decided that the Plan has to be held harmless for the additional hours of neuropsychological testing 
provided on October 7, 2021. 
 
You asked the Plan to be held harmless for the additional hours of neuropsychological testing. You say that you 
would like this claim reprocessed as you were told that the services would be covered. The Plan denied your 
request. The Plan says that there was no medical need for the additional hours of neuropsychological testing. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The additional hours of neuropsychological testing were provided by a contract provider. The file does not 
show that the Plan provided notice that the additional hours of neuropsychological testing would not be 
covered. Under Medicare rules, this means the additional hours of neuropsychological testing is considered 
approved by the Plan.  Therefore, we decided that the Plan has to be held harmless for the additional hours of 
neuropsychological testing provided on October 7, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 4, 
2022. 
 
You asked the Plan to pay for SNF care. You say that SNF care was medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for SNF care have not been met. 
 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the patient 
required skilled nursing services and skilled therapy services on the dates in question. The records did not 
document the need for intravenous medications, new tube feeding or ostomy care or daily complex wound care 
or respiratory care. The latest functional assessment provided to this reviewer was from February 22, 2022; no 
data after this date with regard to her function has been provided. There is no documentation provided to this 
reviewer that the patient's care was anything other than custodial on March 4, 2022.  
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided from March 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vision testing to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve vision testing to be provided by an out-of-network provider. You say that 
the services are medically necessary. The Plan denied your request. The Plan says there are in-network 
providers available to our member. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve vision 
testing to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic addition (L5361). 
 
You asked the Plan to pre-approve a prosthetic addition. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are covered when specific 
criteria are met. 
 
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 prosthetic addition. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the L5361 is not medically 
necessary per LCD L33787. The enrollee was approved for a left AKA prosthesis but per LCD L33787 the 
separate add on request for L5361 is not medically necessary. Per L33787 when an above knee initial 
prosthesis (L5505) or an above knee preparatory (L5560, L5570, L5580, L5590, L5595, L5600) prosthesis is 
provided, prosthetic substitution and/or additions of procedures and components are covered in accordance 
with the functional level assessment except for codes including L5631. When an above knee preparatory 
prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes including L5631. 
 
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 prosthetic addition have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a prosthetic addition (L5361).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay at the psychiatric inpatient hospital. 
 
You asked the Plan to pre-approve continued stay at the psychiatric inpatient hospital. You say that you are 
requesting reconsideration for the denial and provided medical records. The Plan denied your request. The Plan 
says the request for continued stay at the psychiatric inpatient hospitalization level of care does not meet the 
requirements for approval. 
 
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 continued stay at the psychiatric 
inpatient hospital. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
the records provided it was not expected the enrollee would improve in a reasonable period of time for the 
dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
enrollee was compliant with treatment while not showing any acute threats to safety. 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 beyond the dates in question as she did not have dangerousness to self or others and 
was compliant with her treatment. The health plans denial of continued inpatient psychiatric services is 
appropriate. The enrollee did not appear to require inpatient mental health treatment beyond the date in 
question as she was not a danger to herself or others and does not have auditory or visual hallucinations. It did 
not appear that active treatment was taking place beyond the date in question. It did not appear that the services 
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in 
question. I am unable to find an individualized treatment plan however the entire record is not present. It did 
appear that the records were supervised and evaluated by a physician. Based upon review the records provided 
for the admission of the enrollee does not meet the criteria for November 21, 2022, forward as the enrollee was 
not shown to be a danger to herself or others, delusions, auditory or visual hallucinations noted. She was 
cooperative/compliant with treatment while not showing any threats the safety as she awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued stay at the psychiatric inpatient hospital have not been met. 
Therefore, we decided that the Plan does not have to pre-approve continued stay at the psychiatric inpatient 
hospital.