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

 
We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
February 3, 2022. 
 
You asked the Plan to waive the copayment for these services. You say that the copayment is only $250. The 
Plan denied your request. The Plan says the copayment was applied 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 $350 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
Review of the file shows that you received outpatient surgical services to your shoulder on February 23, 2022 
at an outpatient hospital. You have been asked to pay a $350 copayment for these services. These services fall 
within the Medicare-covered surgery or other services provided to you at an outpatient hospital 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. The $250 
copayment is applied for services at an ambulatory surgical center, not outpatient hospital. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on 
February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 19, 2022. 
 
You asked the Plan to pay for the services provided. You say that there is no agreement that the codes are 
included in the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of 
the dialysis center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT), lower extremity, (73700) 
to plan for the Mako robotic arm assisted total knee arthroplasty. 
 
You asked the Plan to pre-approve CT scan. You say that you have recommended the enrollee undergo a 
robotic assisted total knee arthroplasty using the Mako system. You also say that a Mako CT scan for pre-
operative planning should be covered. The Plan denied your request. The Plan says the requested service is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CT scan. Our reviewer says that the 
requested Mako CT scan is not medically necessary. Our physician reviewer found there is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the reviewer found that the requested Mako CT scan for pre-operative planning for the 
total knee arthroplasty, in this case, is not medically reasonable or 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT), lower extremity, (73700) to plan for the Mako robotic arm assisted 
total knee arthroplasty.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient physical therapy visits provided 
from March 2, 2021, to March 25, 2021. 
 
You asked the Plan to waive the copayments for outpatient physical therapy. You say that you paid your 
copays at the time of services, but later found that they were refunded without notice and now the provider is 
requesting these copayments be returned. You feel that you should not be responsible for the provider's 
mistake, and this is a large sum of money for you to pay at once. The Plan denied your request. The Plan says 
these claims were processed correctly, and your copayments were assessed in accordance with your contract. 
The Plan also contacted the provider, who said they had no history of you being refunded for these services and 
then billed again. 
 
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 $20 
copayment for outpatient physical therapy visits.  
 
You have been asked to pay a $20 copayment for each of the outpatient physical therapy 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 copayments for outpatient physical therapy visits provided from March 2, 2021, to 
March 25, 2021.  
 
Your complaint about a possible processing error by the provider is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the provider or Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that payment for the billed CPT codes is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. This means that the profession interpretation must be billed with 
modifier -26 to be considered for payment. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implants (D6010), prefabricated abutments  includes modification and placement (D6056) and implant 
supported porcelain/ceramic crowns (D6065) for teeth 3, 5, 7, 10, 19, 21, 24 and 25). 
 
You asked the Plan to pre-approve multiple endosteal implants, prefabricated abutments and implant supported 
crowns. You say that you are unable to chew without teeth and you have tried dentures several times. The Plan 
denied your request. The Plan says the implants do not meet criteria for coverage. 
 
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 dental benefits in excess of Medicare coverage, the endosteal implants, prefabricated abutments and implant supported crowns are not among those covered services. Therefore, we decided that the 
Plan does not have to pre-approve the surgical placement of implant body: endosteal implants (D6010), 
prefabricated abutments  includes modification and placement (D6056) and implant supported 
porcelain/ceramic crowns (D6065) for teeth 3, 5, 7, 10, 19, 21, 24 and 25).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the pacemaker monitoring provided on 
January 26, 2022. 
 
You asked the Plan to waive the deductible for the pacemaker monitoring. You say that the prior year you did 
not have a copayment for the same procedure. The Plan denied your request. The Plan says the yearly 
deductible was not met prior to the date of service; therefore, the proper deductible was applied for each 
service. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 yearly deductible which applies to the amount you have to pay 
out-of-pocket before we will pay our share for your covered medical services. Until you have paid the 
deductible amount, you must pay the full cost for most of your covered services. Once you have paid your 
deductible, we will begin to pay our share of the costs for covered medical services and you will pay your share 
(your copayment or coinsurance amount) for the rest of the plan year. The deductible does not apply to certain 
services that are listed in the EOC. 
  Prior to the date of service, the total amount paid towards the $250 yearly deductible was $154.95 leaving a 
balance of $95.05 ($250 yearly deductible - $154.95 paid towards deductible) left to pay on the yearly 
deductible. The first total amount allowed for the service was $32.25 and the second total amount allowed for 
the service was $25.22. The total amount allowed for both services was $57.47 ($32.25 total amount allowed + 
$25.22 total amount allowed). Therefore, the $57.47 was applied to the yearly deductible leaving a balance of 
37.58 ($95.05 deductible amount left - $57.47 paid towards yearly deductible).  
 
The item or service you asked the Plan to waive the deductible for falls within the Prosthetic Devices and 
Related Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $250 deductible. This cost sharing is a contractual obligation that had not been met at the time 
the pacemaker monitoring was received on January 26, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible for the pacemaker monitoring provided on January 26, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima for the enrollee. 
 
You asked the Plan to pre-approve Truxima. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that there is no indication their preferred drugs would likely be less 
effective, and/or cause adverse effects for the member. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Truxima. Our reviewer says that 
Truxima is not medically reasonable and necessary. There is no indication that the patient has tried and failed 
Rituxan (rituximab), Ruxience (rituximab-pvvr) or Riabni (rituximab-arrx). There is no indication that the 
Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. Our 
physician reviewer found that the enrollee's condition does not meet step therapy criteria for Truxima. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee does not require daily skilled therapy services on an 
inpatient basis. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. There are no identifiable skilled nursing service 
needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing 
or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service 
criteria for an inpatient basis in a skilled nursing facility setting. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayment for a computed tomography (CT) scan 
performed on March 21, 2022. 
 
You asked the Plan to waive your copayment for a CT scan performed on March 21, 2022. You say that you 
are on a limited income and this copayment is too high. The Plan denied your request. The Plan says you are 
responsible to pay a $250 copayment for diagnostic radiology services that are not ultrasounds. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.  
 
You have been asked to pay a $250 copayment for a CT scan. A CT scan 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 your copayment 
for a computed tomography (CT) scan performed on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment provided on April 
25, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that the service was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
chiropractic manipulative treatment. We found no exception that would require the Plan to pay for the 
chiropractic manipulative treatment. The records provided for review do not show that the service at issue was 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative 
treatment provided on April 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve podiatry services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the podiatry 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
podiatry services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ROMTech Portable Connect Adaptive Rehab Device 
and Blue Tooth Enabled RomTech Knee AccuAngle (E1399, A9900). 
 
You asked the Plan to pre-approve a ROMTech Portable Connect Adaptive Rehab Device and Blue Tooth 
Enabled RomTech Knee AccuAngle. You say that the provider prescribed the device as part of the surgery. 
You also say part of the recovery process requires the device to regain full motion of the leg. The Plan denied 
your request. The Plan says the items at issue do not serve a purpose that is primarily medical in nature. The 
ROMTech Portable Connect Adaptive Rehab Device is considered exercise equipment and would be helpful 
even to those who are not sick or injured. 
 
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 ROMTech Portable Connect Adaptive Rehab Device and 
Blue Tooth Enabled RomTech Knee AccuAngle (E1399, A9900).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for an out-of-network (OON) 
skin lesion removal procedure performed on February 3, 2022. 
 
You asked the Plan to waive the deductible and coinsurance for the OON skin lesion removal. You say that you 
were informed that the provider was in-network. The Plan denied your request. The Plan says the correct 
deductible amount and coinsurance were applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,500 deductible which applies to certain items and services.  
 
Service Allowed Amount Deductible 40% Coinsurance (OON) 
Tissue Transfer $852.06 $852.06 $0.00 
MOHS 1 Stage $331.25 $118.12 $85.25 
MOHS Additional Stage $403.10 $0.00 $161.24 
Total:  $970.18 $246.49 The file shows that you had a total of $970.18 remaining to meet the deductible. This amount was applied first. 
Once the deductible was met, the 40% coinsurance applied to the remaining amounts. The OON services you 
asked the Plan to waive the deductible and coinsurance for fall within the Outpatient Surgery, Including 
Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is $1,500 deductible which applies 
to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the 
OON skin lesion removal was performed on February 3, 2022. Therefore, we decided that the Plan does not 
have to waive the deductible and coinsurance for an out-of-network (OON) skin lesion removal procedure 
performed on February 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing provided on January 20, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered 
for CxBladder testing.  
 
We looked at the file and Medicare rules. The requested CxBladder testing was billed with code 0012M. Per 
LCD L35396, code 0012M is not covered for this testing. Based on this information, we decided that Medicare 
rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay 
for the CxBladder testing provided on January 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 19, 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 must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8 and the file 
shows the services were not performed to a hospital inpatient. Therefore, we decided that the Plan does not 
have to pay for the laboratory services rendered on December 19, 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 you cannot walk without assistance. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for admission to acute rehabilitation. 
 
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 you were admitted for atrial fibrillation, chronic obstructive pulmonary disease and 
congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs. 
While you have a need for physical or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. 
 
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.