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

 
We decided that the Plan does not have to waive the copayment for the hospital outpatient visit provided on 
April 01, 2022, to April 02, 2022. 
 
You asked the Plan to waive the copayment for the hospital outpatient visit. You say that the overnight stay 
was necessary. 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 $40 
copayment for surgery services at an outpatient hospital or ambulatory surgical center. 
 
 
 
 
 
 You have been asked to pay a $40 copayment for the hospital outpatient visit. This item/service falls within the 
surgery services at an outpatient hospital or ambulatory surgical center 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 hospital outpatient visit provided on April 01, 2022, to April 02, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ankle surgery provided on July 07, 
2022. 
 
You asked the Plan to waive the copayment for an ankle surgery. You say that you should not have a 
copayment for this surgery, as this is a follow up surgery to a failed first surgery. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $275 copayment for an ankle surgery. This item/service 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 copayment for an ankle surgery provided on 
July 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repair of ectropion/entropion. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not contain any photographs. 
 
The Plan must follow Medicare rules. Medicare rules say that eye surgeries must be supported by photographs.  
 
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 surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that eyelid surgery for entropion may be considered reconstructive in nature where there is functional 
impairment as documented by preoperative frontal and lateral photographs. The case file does not contain 
photographs. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repair of ectropion/entropion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a telehealth neurology visit provided on 
May 10, 2022. 
 
You asked the Plan to waive the copayment for a telehealth neurology visit. You say that you were not notified 
that there would be a copayment on this telehealth visit. 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 $30 
copayment for Physician/Practitioner services, including doctors office visits. 
 
You have been asked to pay a $30 copayment for a telehealth neurology visit. This item/service falls within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan.  Therefore, we decided that the Plan does not have 
to waive the copayment for a telehealth neurology visit provided on May 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81225, 81227, 81230, 81231, 81232, 81306, 
81335, 81355, 0031U, 0032U, 0033U) provided on May 2, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says this service is non-covered as a screening service. 
 
The Plan must follow Medicare rules. Medicare rules say that only the following codes should be billed for 
Cardiovascular Disease Screening: code 80061 (Lipid panel) which includes codes: 82465 (Cholesterol, serum 
or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol) and/or 84478 
(Triglycerides). 
 
We looked at the file and Medicare rules. This service was for cardiovascular disease screening. The billed 
codes are non-covered for this purpose. Based on this information, we decided that Medicare rules for coverage 
of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic 
testing (81225, 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U, 0033U) provided on May 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the periodontal maintenance (D4910) 
provided on March 1, 2022. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Class 2 Basic Dental Services.  
 
You have been asked to pay $44.16 (Plans allowed amount of $220.80 x 20% coinsurance) for the Class 2 
Basic Dental Service provided. 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 periodontal 
maintenance (D4910) provided on March 1, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 37248 billed for date of service April 18, 
2022. 
 
You asked the Plan to pay for procedure code 37248. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 37248 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 37248 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 37248 billed for date of service April 18, 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. The Plan denied your request. The Plan says you do not meet all 
the required Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 have a past medical history of vertebral compression fractures and are living at 
home with pain and weakness. 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 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. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, we find that the testing described by the billed code 
is considered specimen validity testing which is not separately payable. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on July 14, 2021.
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 you need inpatient rehab so that you can go home 
and take care of yourself. The Plan denied your request. The Plan says this is not medically necessary. The 
services you need can be provided safely in other settings. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs.  There is no documented need for intensive rehabilitation services and medically necessary care can be provided 
in a different level of 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 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: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility care. 
 
You asked the Plan to pre-approve continued skilled nursing facility care. You say that this is medically 
necessary. The Plan denied your request. The Plan says that 106 SNF days have been covered, which exhausted 
your benefit. 
 
Medicare rules say that enrollees are covered for up to 100 days of skilled care in each benefit period. The 
Evidence of Coverage says that enrollees are covered for up to 120 days of skilled care in each benefit period. 
 
The file shows that you received 106 days of SNF care during the benefit period from April 9, 2022, through 
October 8, 2022. The Plan has covered 106 days of SNF care. The Evidence of Coverage clearly states the Plan 
covers 120 days of SNF care during a benefit period. This means that your benefit has not been exhausted and 
you are eligible for 14 additional days. Therefore, we decided that the Plan has to pre-approve continued skilled 
nursing facility care.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the enrollee can safely receive the services they need in 
a long-term care facility with part-time skilled services. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee has a past medical history of diabetes and coronary artery disease and is living at home with dizziness 
and weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in 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 the IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the paclitaxel injections provided from May 
16, 2022, to June 6, 2022. 
 
You asked the Plan to waive the cost share for the paclitaxel injections. You say that there was another 
chemotherapy medication administered that was fully covered. 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 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the paclitaxel injections for a total of $1,275.87. The 
paclitaxel injections fall within the Medicare Part B Prescription Drugs 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 cost share for the paclitaxel injections provided from May 16, 2022, to June 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous device (22869). 
 
You asked the Plan to pre-approve the Vertiflex device. You say that included with this letter is the clinical 
documentation which supports these clinical findings and medical necessity for the procedure. The Plan denied 
your request. The Plan says this procedure is considered experimental and investigational. Medical studies have 
not proven that this device is helpful for the treatment of the enrollee's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion interspinous device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a nitro duet walker (E1399). 
 
You asked the Plan to pre-approve a nitro duet walker. You say that you would like this particular walker 
because this walker has a seat so that if you get tired, you can sit down. The walker also can be pushed like a 
wheelchair. The Plan denied your request. The Plan says enhancement accessories of walkers will be denied as 
non-covered.  A standard walker is available to meet your needs. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The records show the Plan has approved a heavy-duty walker, 
multiple braking system (E0147) and a seat attachment (E0156). Specifically, no other additional 
enhancements are covered. Based on this information, we decided that Medicare rules for coverage of a nitro 
duet walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a nitro duet 
walker (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Medicare-covered outpatient surgery 
provided on April 13, 2022. 
 
You asked the Plan to waive the copayment for Medicare-covered outpatient surgery. You say that the surgery 
performed on April 13, 2022 was a follow-up to the original surgery performed on April 5, 2022. You say that 
you feel you should not be responsible for a 2nd copayment for a follow-up surgery. 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 $250 
copayment for an outpatient surgery. 
 
You have been asked to pay a $250 copayment for Medicare-covered outpatient surgery. This item/service falls 
within the an 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 copayment for 
Medicare-covered outpatient surgery provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4342) of all 
four quadrants 
 
You asked the Plan to pre-approve the scalings and planings. You say that these scalings and planings are 
medically necessary. The Plan denied your request. The Plan says your benefit for the requested services has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on date of service February 14, 2022, and 
February 15, 2022. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and 
root planings (D4342) of all four quadrants
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services rendered on August 30, 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 procedure code 97110 is not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for the services. 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 physical therapy services rendered on August 30, 2021.