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

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to be in a facility where you can get your 
medications and physical therapy. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for coverage. 
 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 daily 
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs 
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have 
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional 
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled 
nursing facility SNF setting. 
 
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 pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery/gastric bypass Roux-en-Y with 
esophagogastroduodenoscopy (EGD) for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is needed for gastroparesis and 
gastrointestinal reflux disease (GERD) The Plan denied your request. The Plan says this is considered 
experimental, investigational, and unproven for treatment of any condition other than obesity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has cirrhosis, gastroesophageal reflux and gastroparesis by 
history. The record does not include a gastric emptying study.  The record provided does not establish the 
medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of 
the coverage criteria are not satisfied. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bariatric surgery/gastric bypass Roux-en-Y with esophagogastroduodenoscopy (EGD) for 
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided by a 
network facility from October 17, 2021, to October 26, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you had to be 
transferred to a second hospital and you should not be charged because it was a continuation from your initial 
inpatient stay. The Plan denied your request. The Plan says you have been asked to pay 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 $50 
copayment each day for days 1-5, per admission and a $0 copayment each day for days 6-90, per admission.   
You have been asked to pay a $50 copayment for days 1 to 5 of the inpatient hospital stay. ($50 x 5 = $250). 
The inpatient hospital stay falls within the Inpatient Hospital Care benefit category. The record shows the 
second hospital stay is considered a separate hospital admission. 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 inpatient hospital stay provided by a network facility from October 17, 2021, to October 26, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Myomo website states that the MyoPro device is contraindicated for severe shoulder 
subluxation, pain in the affected limb with facilitated motion, and rigid spasticity in the affected muscle groups. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as 
conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, 
conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable 
and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a 
malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional 
standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the 
literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic 
arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G orthotic device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest with 
contrast. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested service is medically 
necessary. The Plan denied your request. The Plan says the current standard of medical practice is to perform a 
chest x-ray before considering a CT scan of the chest. 
 
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 of the chest. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has no chest x ray 
results. Such an exam would be the first imaging study in the evaluation of a chronic cough in a nonsmoker. 
 
 
 
 
 
 
 
 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 of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest with contrast.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an epidural injection, the percutaneous 
implantation of a neurostimulator electrode, and the revision of an epidural catheter provided from May 7, 
2021, to September 13, 2021. 
 
You asked the Plan to waive the copayments for an epidural injection, the percutaneous implantation of a 
neurostimulator electrode, and the revision of an epidural catheter. You say that you were told that the services 
were out-of-network but you only go to in-network providers. The Plan denied your request. The Plan says the 
claims were processed correctly and you are being charged the correct 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 $350 
copayment for outpatient surgery, including services provided at ambulatory surgical centers.  You received an epidural injection at an ambulatory surgical center on May 7, 2021. An epidural injection is 
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $350 copayment.  
 
You received the percutaneous implantation of a neurostimulator electrode at an ambulatory surgical center on 
July 6, 2021. The percutaneous implantation of a neurostimulator electrode is considered an outpatient surgical 
procedure. Therefore, you are responsible to pay the $350 copayment. 
 
You received the revision of an epidural catheter at an ambulatory surgical center on September 13, 2021. The 
revision of an epidural catheter is considered an outpatient surgical procedure. Therefore, you are responsible 
to pay the $350 copayment. 
 
The total amount you owe is: $1,050.  
 
You have been asked to pay the total copayment amount of $1,050 for an epidural injection, the percutaneous 
implantation of a neurostimulator electrode, and the revision of an epidural catheter. An epidural injection, the 
percutaneous implantation of a neurostimulator electrode, and the revision of an epidural catheter fall within 
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayments for an epidural injection, the 
percutaneous implantation of a neurostimulator electrode, and the revision of an epidural catheter provided 
from May 7, 2021, to September 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary to avoid grade III and 
IV toxicities to the rectum, pelvic bone, and bladder. The Plan denied your request. The Plan says the standard 
of care for radiation therapy for prostate cancer is standard radiation therapy including intensity modulated 
radiation therapy (IMRT). 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found routine use of proton therapy for pelvic/prostate radiation is not within accepted standards of medical 
practice. No comparison plan is provided for the enrollee showing an unacceptable non-proton based plan. 
 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ureteral stent procedure and 
cystourethroscopy provided by a network facility from September 17, 2021, to September 27, 2021. 
 
You asked the Plan to waive the copayments for the ureteral stent procedure and the cystourethroscopy. You 
say that you cannot afford to pay these bills on your limited income. The Plan denied your request. The Plan 
says you have been asked to pay 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 $400 
copayment for outpatient surgery in an outpatient hospital facility.  
 
You have been asked to pay a $400 copayment for the ureteral stent procedure and a $400 copayment for the 
cystourethroscopy. The ureteral stent procedure and the cystourethroscopy fall within the Outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the ureteral stent procedure and cystourethroscopy 
provided by a network facility from September 17, 2021, to September 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance ride provided by an out-of-
network provider on September 8, 2021 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you had to be transported to 
another hospital. You say you did not know such a small distance would be that expensive. You say you are 
unable to pay this amount. The Plan denied your request. The Plan says you have been asked to pay 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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
 You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the 
Ambulance Services benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the 
ambulance ride provided by an out-of-network provider on September 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided by a 
network dermatologist on November 11, 2021. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you were advised that 
after the first office visit you would not have to pay for anymore visits. The Plan denied your request. The Plan 
says you have been asked to pay 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 $40 
copayment for each specialist visit for Medicare-covered benefits.  
 
 You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit 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 the specialist office visit provided by a network dermatologist on 
November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 18, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that prior authorization is not required for an office visit 
and the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-
network provider and the service provided was not urgent or emergent. 
  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 an office visit provided on March 18, 2021, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve AccuChek test strips (A4253). 
 You asked the Plan to pre-approve the AccuChek test strips. You say that the AccuChek test strips are 
medically necessary. The Plan denied your request. The Plan says only OneTouch brand strips are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  
 
We looked at the file and Medicare rules. There was no clinical documentation provided to show why the plan 
preferred brand would be unsafe or ineffective for the enrollee. Based on this information, we decided that 
Medicare rules for coverage of the AccuChek test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve AccuChek test strips (A4253).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 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 the services were not billed correctly. 
 
  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on September 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on November 2, 
2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were injured during a blood 
pressure reading and went to the emergency room to make sure you did not have a blood clot. The Plan denied 
your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $90 
copayment for emergency care.  
 
 
 You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on 
November 2, 2021.  
 
We note your complaint that your arm was injured during a blood pressure reading. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the cystourethroscopy with insertion of indwelling ureteral stent coded 
52332 and billed with the -59 modifier provided on July 29, 2021. 
 
You asked the Plan to pay for the cystourethroscopy billed with the -59 modifier. You say that this service as 
billed is supported with the medical documentation. The Plan denied your request. The Plan says that the use of 
the 59 modifier is not supported according to Medicare coding regulations. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the cystourethroscopy billed with the -59 
modifier Our reviewer says that the documentation does support the services as billed with the -59 modifier. 
Our physician reviewer found the operative report contains documentation of two distinct procedures at 
different sites. The enrollee underwent cystourethroscopy with resection of a tumor in the bladder, followed by 
placement of a double-J stent in the right ureter. Therefore, the use of the 59 modifier with 52332 is supported.  
 
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 cystourethroscopy billed with the -59 modifier have been met. Therefore, 
we decided that the Plan has to pay for the cystourethroscopy with insertion of indwelling ureteral stent coded 
52332 and billed with the -59 modifier provided on July 29, 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.