Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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. Specifically, medically necessary services can be obtained in a lower level of care. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the laparoscopy (43775) provided on May 11, 2021.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan has not addressed how it has handled CPT code 43775.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence as to why CPT code 43775 was denied. The Plan has not forwarded a claim or remittance advice for this code. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the laparoscopy (43775) provided on May 11, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Stereotactic Body Radiation Therapy (SBRT). 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that that medical necessity is not evident that you have triple positive breast cancer 
post mastectomy with metastases including to the lung. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Stereotactic body 
radiation therapy (SBRT) is a technique that utilizes precisely targeted radiation to a tumor while minimizing 
radiation to adjacent normal tissue. This targeting allows treatment of small or moderate-sized tumors in either 
a single or limited number of dose fractions. It has been shown to be an appropriate alternative to surgery in 
patients with significant comorbidities. Use in this setting is a considered a standard of care and is safe and 
effective. Our physician reviewer found that your condition meets criteria for coverage of these 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Stereotactic Body Radiation Therapy (SBRT).  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to waive the cost sharing for the implantable knee prosthesis (C1776) and the 
drugs provided during outpatient hospital surgery on October 6, 2021. 
 
You asked the Plan to waive the cost sharing for the implantable knee prosthesis (C1776) and the drugs. You 
say that you already paid the copayment for the outpatient surgery and now you're receiving a bill for these 
additional items. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan appears to be charging you coinsurance for Part B drugs 
you received during outpatient surgery.  The Plan has failed to provide a detailed listing of these drugs or even 
a claim showing that these drugs were billed.  Without this information, we cannot determine that this cost 
sharing was charged correctly.  Due to the Plan's failure to support its billing for this cost sharing, we find that 
the Plan must waive the coinsurance charged for these drugs. 
 
In addition, we find that the Plan must waive the coinsurance charged for the implanted knee prosthesis (code 
C1776) you received.  The Plan claims that you are required to pay 20% coinsurance for prosthetic devices.  
We do not agree with the Plan's assessment here.  Medicare rules say that implanted prosthetic devices are not 
separately payable by the Durable Medical Equipment, Prosthetic, and Orthotic supplier Medicare 
Administrative contractor (DMEPOS MAC).  Rather, these items are part of the payment made to the hospital 
or facility. Only items given 'pass-through' status are permitted to be separately charged.  Medicare issues a 
listing of those devices granted 'pass-through' status in its Claims Processing Manual.  The Manual says that the 
implantable knee prosthesis you received (code C1776) no longer has pass-through status as of December 31, 
2002.  Because this device does not have pass-through status, it must be included in the cost of the surgery 
itself and is not a separate charge. Because this device cannot be separately charged, it is not appropriate for the 
Plan to assess separate cost sharing for this item. Therefore, we decided that the Plan has to waive the cost 
sharing for the implantable knee prosthesis (C1776) and the drugs provided during outpatient hospital surgery 
on October 6, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine PCR testing rendered on October 25, 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 testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 
 
We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care 
for the diagnosis and treatment of a UTI. 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 
urine PCR testing rendered on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics you purchased on September 9, 2021. 
 
You asked the Plan to pay for foot orthotics. You say that your doctor knows that this is a need and approved of 
it. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics you purchased on 
September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (22514). 
 
You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (percutaneous vertebroplasty (PVP) or 
kyphoplasty (PKP)) is covered in patients with BOTH the criteria mentioned in the Medicare Rules section of 
this letter. 
 
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 percutaneous vertebral 
augmentation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
records do not contain recent imaging and more information is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (22514).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received from a freestanding lab on September 9, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you were told that this bill was a mistake. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you are only being charged $14.53 for these lab services, which is less than your copayment obligation.
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 $15 copayment for lab services at a freestanding laboratory. You have been asked to pay a $15 copayment for the lab services. 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 lab services you received from a freestanding lab on September 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the electrocardiogram (ECG) monitoring 
and reporting (93271, 93270) provided on May 25, 2021, and the office visit (99213) and ultrasound of the 
head and neck (76536) provided on September 10, 2021. 
 
You asked the Plan to waive the copayments for the diagnostic testing services. You say that these services are 
necessary, and these bills should be paid. The Plan denied your request. The Plan says these services are 
covered by your Plan, and the Plan has paid their portion of the cost for this care. These claims were processed 
correctly, and your cost-share was assessed in accordance with your contract. 
 
 
  
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 $150 
copayment for diagnostic procedures and tests, a $40 copayment for physician specialist services, and a $110 
copayment for x-ray services performed by a provider other than your primary care physician. 
 
You have been asked to pay a $149.86 copayment for the ECG monitoring and reporting services provided on 
May 25, 2021. ECG monitoring and reporting falls within the diagnostic procedures and tests benefit category. 
You have been asked to pay a $40 copayment for the office visit with a specialist and a $70 copayment for the 
ultrasound provided by a specialist, for a total copayment of $110 for the services provided on September 10, 
2021. 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 electrocardiogram (ECG) monitoring and 
reporting (93271, 93270) provided on May 25, 2021, and the office visit (99213) and ultrasound of the head 
and neck (76536) provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 2, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The file does not contain documentation of an established 
relationship between the enrollee and the ordering provider. Without a record showing that this provider is 
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on September 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that you require continued skilled care with 
goal to return home. The Plan denied your request. The Plan says you have exhausted your skilled nursing 
facility Medicare benefit. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 19, 2021, 
through February 11, 2022. The Plan has covered 100 days of SNF care. 
 
 
 Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the positron emission tomography (PET) 
scan and the regadenoson injection you received on August 26, 2021. 
 
You asked the Plan to waive the cost sharing for the PET scan and the regadenoson injection. You say that you 
were not told about this cost sharing prior to this service.  You said that you had known, you would not have 
had the service. The Plan denied your request. The Plan says you were charged this cost sharing 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 $300 
copayment for PET scans and 20% coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a $300 for the PET scan and 20% coinsurance for the regadenoson injection. The regadenoson injection is a Medicare Part B drug. 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 sharing for 
the positron emission tomography (PET) scan and the regadenoson injection you received on August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on May 20, 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 the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on May 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a psychiatric diagnostic evaluation 
provided on October 20, 2021. 
 
You asked the Plan to waive the copayment for a psychiatric diagnostic evaluation. You say that you say that 
you did not see your primary care physician that day. 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 
copayment for an individual mental health visit.  
 
You have been asked to pay a $20 copayment for a psychiatric diagnostic evaluation. A psychiatric diagnostic 
evaluation falls within the Outpatient Mental Health Care benefit category. The medical records show you received a psychiatric diagnostic evaluation from a social worker. The Explanation of Benefits shows the social 
worker billed the service under your primary care physician. Although you did not see your primary care 
physician for the service the social worker can bill to the Plan under his name. 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 psychiatric diagnostic evaluation provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional crown (D2799) provided on September 1, 
2021. 
 
You asked the Plan to pay for the provisional crown. You say that this service should be covered. The Plan 
denied your request. The Plan says this service is not covered by your dental benefit. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
provisional crown (D2799) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a 
pulmonologist on July 13, 2021. 
 
You asked the Plan to waive the copayment for the pulmonology visit. You say that you don't feel as though 
you should have to pay this copayment as the only thing that happened during the visit was that you had blood 
work taken. The Plan denied your request. The Plan says you were charged this copayment 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 in-person specialist visits.  
 
You have been asked to pay a $40 copayment for the pulmonology visit. the pulmonology visit falls within the 
in-person specialist visits benefit category. This copayment applies each time you visit the office, regardless of 
the extent of service you receive during the visit. 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 office visit you had with a pulmonologist 
on July 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 12, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an appropriate modifier was not billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on October 12, 2021.