Persius/hicric huggingface dataset:
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 there are no services available at the 
LTACH that you require that are not available at the health care setting being offered by the health plan. The 
health plan has approved ongoing care in the current acute care facility. The requested LTACH services are not 
medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished 
safely and effectively only on an inpatient basis. 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 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 there are no services available at the LTACH that you require that are not available at 
the health care setting being offered by the health plan. The health plan has approved ongoing care in the 
current acute care facility.  
 The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis 
and condition and able to be furnished safely and effectively only on an inpatient basis. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ER visit provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you weren't even seen and that you 
left the hospital. The Plan denied your request. The Plan says the copayment was applied correctly. Records 
show that your vitals were taken and recorded which is considered the start of services. 
 
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 $90 
copayment per visit, for ER visits.  
 
You have been asked to pay $90 for the ER visit. An ER visit 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 the ER visit provided on January 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 22, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advance. 
 
 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 the lab services provided on January 22, 2022 by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye exam provided on January 24, 2022. 
 
You asked the Plan to waive the copayment for an eye exam. You say that an optometrist is a specialist and 
you are requesting the copayment be reduced to $45. The Plan denied your request. The Plan says you have 
been 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 $50 
copayment for per Medicare-covered visit.  
 
You have been asked to pay a $50 copayment for an eye exam. The eye exam falls within the Vision 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 an eye exam provided on 
January 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sigmoidoscopy (45330) and unlisted colon procedure 
(45399) provided on December 13, 2021. 
 
You asked the Plan to pay for the sigmoidoscopy (45330) and unlisted colon procedure (45399). You say that 
the documents support the billing and the services were medically necessary. You say that the claim should be 
reviewed and reprocessed correctly for payment. The Plan denied your request. The Plan says procedure code 
45399 is not supported by the medical records submitted. The Plan also says procedure code 45330 is inclusive 
to procedure code 44207. 
 
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 45330 is sigmoidoscopy, flexible; diagnostic, including 
collection of specimen(s) by brushing or washing, when performed (separate procedure). The CPT Code 
Manual definition of code 45399 is unlisted procedure, colon. 
 
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 sigmoidoscopy (45330) and unlisted colon procedure 
(45399). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for 
coverage. Our reviewer found that if an endoscopic procedure is performed at the same patient encounter as a 
non-endoscopic procedure, the endoscopic procedure is not separately reportable. In addition, the operative 
report does not describe an unlisted colon procedure, and therefore cannot be verified. 
 
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 sigmoidoscopy (45330) and unlisted colon procedure (45399) have not been 
met. Therefore, we decided that the Plan does not have to pay for the sigmoidoscopy (45330) and unlisted 
colon procedure (45399) provided on December 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies.  The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 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 the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. Documentation does not support the medial necessity for admission to an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on 
January 18, 2022. 
 
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that a copayment of $25 is 
incorrect. You say that per the ID card the copayment should be $20 for a specialist visit. The Plan denied your 
request. The Plan says you have been 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $25 copayment for Medicare-covered non-radiological diagnostic services.  
 
 
 The enrollee has been asked to pay a $25 copayment for the pacemaker evaluation. The evaluation of a 
pacemaker falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the pacemaker evaluation 
provided on January 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services rendered on October 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 claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. 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 
pay for the pathology services rendered on October 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF 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 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 the enrollee needs physical and occupational therapy and they can be provided in a 
lower intensity setting such as in a skilled nursing facility. Documentation does not support the medial 
necessity for admission to an IRF. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Lutetium lu 177 dotatate. 
 
You asked the Plan to pre-approve Lutetium lu 177 dotatate. You say that the services are necessary. The Plan 
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
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 Lutetium lu 177 dotatate. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has exhausted 
standard treatment options. The use of Lutetium lu 177 dotatate is supported by the medical literature for the 
treatment of this disorder. The service is reasonable and medically necessary and likely to be safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lutetium lu 177 dotatate have been met. Therefore, we decided that the Plan 
has to pre-approve Lutetium lu 177 dotatate.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that the copayment amount is erroneous 
and that the claim was processed incorrectly. You say it should have processed as an outpatient visit and the 
copayment waived. The Plan denied your request. The Plan says you have been 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 $25 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $25 copayment for an office visit. The office 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 office visit provided on January 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pacemaker surgery provided on 
December 27, 2021. 
 
You asked the Plan to waive the coinsurance for the surgery. You say that you did not have a choice and 
technology has improved pacemakers. The Plan denied your request. The Plan says you have been charged less 
than the standard coinsurance 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 10% 
coinsurance for each in-network Medicare-covered outpatient hospital facility visit. 
 
 
 
 
 You have been asked to pay $466.72, which is less than the standard 10% coinsurance for the pacemaker 
surgery. The pacemaker surgery falls within the Outpatient Surgery 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 the pacemaker surgery provided on December 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the carotid evaluation rendered on December 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 services are 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, bilateral quantitative carotid intima media thickness and carotid atheroma 
evaluation, 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 carotid evaluation rendered on 
December 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visits on July 19, 2021 and August 2, 
2021. 
 
You asked the Plan to waive the deductible for office visits. You say that you should not have to pay this bill 
because you were told the provider was in-network but then the claim was processed as out-of-network. The 
Plan denied your request. The Plan says the deductible 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 $750 
out-of-pocket deductible which applies to certain items and services.  
 
  The item or service you asked the Plan to waive the deductible for falls within the Physician/Practitioner 
services, including doctors office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that the $750 deductible applies to office visits. 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 deductible for the office visits on July 19, 2021 and August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an epidural injection provided on November 29, 2021. 
 
You asked the Plan to pay for an epidural injection. The Plan denied your request. The Plan says the Health 
Plan has not received the required clinical records to support the medical necessity of the service for the date of 
service requested. The records provided are undated and unsigned. There is insufficient documentation of 
response to prior injections. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural injection provided on 
November 29, 2021 have been met. Therefore, we decided that the Plan does not have to pay for an epidural 
injection provided on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical aortic valve replacement (SAVR). 
 
You asked the Plan to pre-approve SAVR. 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. 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 SAVR. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case.  Our physician 
reviewer found at this time the requested SAVR would not be considered medically necessary in this enrollee's 
clinical management based on the submitted 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 SAVR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve surgical aortic valve replacement (SAVR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services provided on July 24, 2020. 
 
You asked the Plan to pay for the surgical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare 
program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the surgical services provided on July 
24, 2020.