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

 
We decided that the Plan does not have to waive the copayment for the x-ray of the shoulder you had at an 
outpatient hospital facility on June 23, 2021. 
 
You asked the Plan to waive the copayment for the x-ray. You say that this is the only x-ray provider in your 
county. You said that the Plan must honor and pay charges for radiology in your county. The Plan denied your 
request. The Plan says this claim was not denied.  Rather, the allowed amount for this x-ray ($79.66) is less 
than your copayment obligation, so you are responsible for the full allowed 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 $100 
copayment for basic radiology services at an outpatient hospital.  
 
 You have been asked to pay a $100 copayment for the x-ray. 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 x-ray of the shoulder you had at an outpatient hospital facility on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complex trunk repair (13101 and 13102) provided on 
July 1, 2020. 
 
You asked the Plan to pay for the complex trunk repair. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says these codes were billed with an 
inappropriate modifier combination. 
 
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 CPT codes 13101 and 13102 are not supported in the medical record. Specifically, these codes 
were billed with modifiers 59 and XS. It is not appropriate to bill these modifiers together. Based on this 
information, we decided that Medicare rules for coverage of the complex trunk repair have not been met. 
Therefore, we decided that the Plan does not have to pay for the complex trunk repair (13101 and 13102) 
provided on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve THE lumbar facet joint radiofrequency ablation 
procedure(s) (64635, and 64636). 
 
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation procedure(s). 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 the thermal radiofrequency destruction of cervical, 
thoracic, or lumbar paravertebral facet joint (medial branch) nerves are considered medically reasonable and necessary for patients who meet ALL the criteria listed 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 lumbar facet joint radiofrequency 
ablation procedure(s). Our reviewer says that the service is not medically necessary. Our physician reviewer 
found there has not been a second confirmatory set of diagnostic Medial Branch Blocks (MBBs). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar facet joint radiofrequency ablation procedure(s) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve THE lumbar facet joint radiofrequency 
ablation procedure(s) (64635, and 64636).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient pacemaker replacement 
procedure at an outpatient hospital facility on May 12, 2021. 
 
You asked the Plan to waive the coinsurance for the outpatient pacemaker replacement procedure. You say that 
the pacemaker had to be replaced due to a manufacturing defect.  You said that this was an unexpected medical 
procedure and this coinsurance is a financial hardship. The Plan denied your request. The Plan says the enrollee 
was charged this coinsurance correctly. The Plan says that the coinsurance was only assessed up to the 
remaining out-of-pocket maximum ($942.46). 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee?s contract with the Plan clearly says that enrollees 
must pay 10% coinsurance for outpatient surgery.  
 The enrollee has been asked to pay 10% coinsurance for the outpatient pacemaker replacement procedure. The 
outpatient pacemaker replacement procedure falls within the outpatient surgery benefit category. This cost 
sharing applies regardless of the reason for the procedure. This means that the enrollee has been asked to pay 
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for the outpatient pacemaker replacement procedure at an outpatient hospital facility on May 12, 
2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
March 7, 2021, to April 5, 2021.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, in addition
to reporting a visit line using the G codes, an additional line item with the same revenue code and date of
service, reporting one of the three Q codes must be submitted on the claim. Review of the file does not support
that a Q code was billed with these services. Therefore, we decided that the Plan does not have to pay for the
home health services provided to the enrollee from March 7, 2021, to April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed dental bridge comprised of retainer crowns (D6750) on teeth #11 and #13 and a pontic/false tooth (D6240) on tooth #12.

You asked the Plan to pre-approve the fixed bridge. You say that this service is necessary. The Plan denied your request. The Plan says the criteria for the fixed partial denture/bridge are not met and this request is not medically necessary.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The Plan covers the placement of a fixed prosthetic appliance only when the request is for the anterior (front) segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. The placement of a fixed prosthetic appliance will only be considered for the anterior segment of the mouth to replace a single maxillary (upper) anterior tooth or replace two adjacent mandibular (lower) teeth. Fixed prosthetic appliances are not a benefit when there is one or more missing posterior teeth in the same arch.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. Specifically, the tooth that will be replaced with a pontic is classified as a posterior (back) tooth. Additionally, there is no documentation or narrative indicating that you have a physical or neurological disorder that would preclude placement of a removable prosthetic appliance. Therefore, we decided that the Plan does not have to pre-approve a fixed dental bridge comprised of retainer crowns (D6750) on teeth #11 and #13 and a pontic/false tooth (D6240) on tooth #12.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist 
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 a review of current medical literature shows that these services do not have proven 
benefit and are considered experimental and investigational. 
 
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 there are no detailed medical notes from any treating physician, occupational therapist or physical 
therapist are included in the available records demonstrating the necessity of the requested device over other 
therapies. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-
matched conventional upper limb exercise therapies" with unproven benefit in the home environment. In 
addition, records show the enrollee has a left shoulder subluxation which may be a contraindication to use of 
the device.  
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 a powered upper extremity range of motion assist device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.

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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that a meta-analysis of available studies does not show significant benefit over the standard therapy. The procedure is deemed experimental/investigational. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift (E2300), footplates, cellphone holder, 
hydration system, pole motors, tube arm, transit option, lap belt and joystick. 
 
You asked the Plan to pre-approve a seat lift, footplates, cellphone holder, hydration system, pole motors, tube 
arm, transit option, lap belt and joystick. You say that the items are medically necessary. The Plan denied your 
request. The Plan says the cell phone holder, hydration system, pole motors and tube arm do not primarily 
serve a medical purpose. The seat lift and footplates are not covered benefits. The transit option is not covered 
as it is not used inside the home and the lap belt and joystick are included in the base package for the group 
three wheelchair. 
 
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 seat lift (E2300), footplates, cellphone holder, hydration 
system, pole motors, tube arm, transit option, lap belt and joystick.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Monovisc injection. 
 
You asked the Plan to pre-approve a Monovisc injection. You say that you need this to avoid surgery. The Plan 
denied your request. The Plan says another repeat injection is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat injections for shoulder arthritis are limited 
to a single repeat course. 
 
We looked at the file and Medicare rules. The records show that you have already had a repeat course of 
Monovisc. Based on this information, we decided that Medicare rules for coverage of a Monovisc injection 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Monovisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services rendered on 
April 19, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that your provider 
instructed you to go to the emergency room where a doctor performed some tests. You also say that the 
emergency room doctor told your wife that you would be admitted for at least overnight. The Plan denied your 
request. The Plan says you were 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 an $85 
copayment for Emergency Care.  
 
 
  
You have been asked to pay an $85 copayment for each visit to an emergency room. The records do not show 
that there was a written order by your provider to admit you into the hospital. 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 room services rendered on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chest x-ray you had on June 4, 2021. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that this x-ray was part of your pre-op 
workup for surgery on June 7, 2021. You said that you had major surgery last year and there was no extra 
charge for the pre-op x-ray for that procedure. 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 $35 
copayment for x-rays.  
 
You have been asked to pay a $35 copayment for the chest x-ray. This copayment applies regardless of the 
reason for the test and regardless of what you may have paid in the past. 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 chest x-ray you had on June 
4, 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 inpatient rehabilitation is medically necessary for 
this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The 
enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care. 
 
  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. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you $530.34 for three Covid-19 tests taken to return to the 
United States.  
 
You asked the Plan to reimburse you for Covid-19 testing. You say that you were told this testing would be 
covered. The Plan denied your request. The Plan says only those tests taken within the United States are 
covered by the Plan or by Medicare. The Plan states they will cover $261 for the test taken in California. The 
other tests completed in Nigeria are not covered under Medicare. 
 
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 only emergency 
services to prevent loss of life or limb are covered outside of the United States. Medicare will not reimburse 
Covid-19 testing for employment purposes or for those choosing to leave the country and/or re-enter the 
country. Those situations do not fall under the category of medical need or emergency services. Therefore, we 
decided that the Plan does not have to reimburse you for this testing.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for injections of ferric carboxymaltose and 
administration services provided on June 11, 2021, and June 18, 2021. 
 
You asked the Plan to waive the cost-sharing for Part B drugs and hospital visits. You say that you do not 
understand how the cost-sharing was calculated for these claims. The Plan denied your request. The Plan says 
the cost-sharing amounts you are being charged are correct. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Part B drugs and $335 copayment for drug administration services at an in-network outpatient 
hospital facility. The allowed amount of the Part B drugs for each visit is $606.75, resulting in a coinsurance 
amount of $121.35 for each visit. For each visit, you have been asked to pay the allowed amount of $191.60 for 
drug administration services because this is less than the $335 copayment for hospital/facility charges. 
Therefore, the total cost-sharing for each visit is $312.95. There were two visits, resulting in a total cost-sharing 
amount of $625.90. 
 
You have been asked to pay 20% coinsurance for Part B drugs and less than $335 copayment for each hospital 
visit. Part B drugs and hospital visits fall within the "Medicare Part B Prescription Drugs" and "Outpatient 
Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers" benefit categories. 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 injections of ferric 
carboxymaltose and administration services provided on June 11, 2021, and June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pain management services provided on June 17, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you were unable to obtain the authorization 
number due to the short period. The Plan denied your request. The Plan says the services were not urgent, 
emergent, or approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The file shows that the enrollee was seen for a follow up visit. The provider in this case is not a network 
provider with the Plan. The Plan had network providers available who could have provided the services at issue 
in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the 
Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the pain 
management services provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 20, 
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 the services were not urgent or emergent, and they were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on 
April 20, 2021.