Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 07, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on December 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery 
pressure monitor. 
 
You asked the Plan to pre-approve the CardioMEMs procedure. You say that this is a beneficial procedure that 
can reduce hospitaization. The Plan denied your request. The Plan says there is not sufficient literature support 
for this treatment. 
 
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 CardioMEMs procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). 
The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. 
 
Nonetheless, there remains a shorage of randomized, blinded clinical studies examining long-term clinical 
outcomes establishing the value of CardioMEMS in patient management. As a result, at this time, the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 CardioMEMs procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of the CardioMEMs pulmonary artery pressure monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on June 06, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on June 06, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation treatment (IMRT; 77014, G6013, 
G6015). 
 
You asked the Plan to pre-approve the IMRT. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is experimental and investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that IMRT is covered when the target volume is 
concave/convex, or the target volume is in close proximity to critical structures that must be protected. 
 
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 IMRT. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the use of IMRT for the treatment of breast cancer is becoming more widely used. In general, IMRT 
is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation 
oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal 
structures. For patients with an intact breast after resection, IMRT has been shown to improve skin and breast 
toxicity. For post-mastectomy radiation, IMRT has been shown to significantly reduce the dose-volume 
exposure of the ipsilateral lung and (for left sided breast cancer which does not apply to this patient) the heart. 
For this patient with a complex target volume (encompassing regional node) the clinically meaningful benefit 
of IMRT is plausible and IMRT would be standard of care. It is also plausible that with this patients obesity 
that IMRT would be necessary for dose homogeneity.    
 
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 IMRT have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation treatment (IMRT; 77014, G6013, G6015).  
 
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: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the central venous tube removal provided 
on March 14, 2022. 
 
You asked the Plan to waive the copayment for the central venous tube removal. You say that previous surgery 
charged had been waived. 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 $295 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $295 copayment for the central venous tube removal. This item/service falls 
within the in-network 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 the central venous tube removal provided on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on November 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told this provider was in-network. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services provided on November 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on August 02, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee was in a nursing home and the 
admission authorization should cover these services. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on August 02, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the COVID-19 test provided on September 
28, 2022. 
 
You asked the Plan to waive the copayment for the COVID-19 test. You say that you needed to take a COVID-
19 test. 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 $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for the COVID-19 test. This item/service falls within the 
urgently needed 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. However, since the allowed amount is less than the standard copayment, you only owe 
$64.57. Therefore, we decided that the Plan does not have to waive the copayment for the COVID-19 test 
provided on September 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve additional routine transportation trips. 
 
You asked the Plan to approve these services. You say that you need trips for future appointments. The Plan 
denied your request. The Plan says the request exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 24-one way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used all 24 
one-way trips allowed by your routine transportation supplemental benefit. Based on this information, we 
decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, 
we decided that the Plan does not have to approve additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on 
October 27, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you could not help 
but to have an out-of-network provider and you should not be held responsible. 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 $280 
copayment for out-of-network ambulance services. 
 
You have been asked to pay a $280 copayment for the ambulance transportation. This item/service falls within 
the out-of-network 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 transportation provided on October 27, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computed tomography, limited or localized follow-up study 
rendered on September 15, 2022. 
 
You asked the Plan to pay for the services. You say that the claim is billed correctly. The Plan denied your 
request. The Plan says code 76380-26 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 76380 is "Computed tomography, limited or localized 
follow-up study." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
include documentation to support CT was not performed with the bronchoscopy, and therefore would in 
included in the primary procedure. 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for computed tomography, limited or localized follow-up study rendered on September 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond April 14, 
2023. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee requires 
continued inpatient care. The Plan denied your request. The Plan says the enrollee no longer requires inpatient 
care for her mental health condition. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric care. 
Our reviewer says that ongoing inpatient psychiatric care is not considered medically reasonable and necessary. 
Our physician reviewer found This 70-year-old female was admitted to the acute inpatient psychiatric 
hospitalization on March 14, 2023, with Major Neurocognitive Disorder, Due To Multiple Etiologies without 
Behavioral Disturbance, Moderate, Depression, Unspecified Depressive Type, Unspecified Mood Disorder, 
Generalized Anxiety Disorder, Alcohol Use Disorder, Severe, Dependence, Insomnia Due To Other Mental 
Disorder and Major Depressive Disorder, Recurrent, Severe without Psychosis. Based upon review the records 
provided it was not expected this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The patient was 
compliant with treatment while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient psychiatric care beyond April 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency room visit provided on 
September 17, 2022. 
 
You asked the Plan to reduce the copayment for the emergency room visit. You say that you could not go to 
urgent care because they do not handle the type of issue you were having. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for the emergency room visit. This item/service 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 reduce the copayment for the emergency room visit 
provided on September 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation - new or established patient 
(D0150), intraoral  comprehensive series of radiographic images (D0210), and caries risk assessment and 
documentation, with a finding of moderate risk  (D0602) provided on November 17, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed to change dentists and x-rays were 
taken by the new dentist because they do not share that information with other dentists The Plan denied your 
request. The Plan says your benefit for the requested item or service 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 caries 
risk assessment and documentation, with a finding of moderate risk is not among those covered under this 
benefit. The record shows your benefit for the comprehensive oral evaluation and intraoral  comprehensive 
series of radiographic images was exhausted on date of service July 13, 2022. Therefore, we decided that the 
Plan does not have to pay for a comprehensive oral evaluation - new or established patient (D0150), intraoral  
comprehensive series of radiographic images (D0210), and caries risk assessment and documentation, with a 
finding of moderate risk  (D0602) provided on November 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the parathyroid gland surgery provided on 
November 03, 2022. 
 
You asked the Plan to waive the coinsurance for the parathyroid gland surgery. You say that you are unsure 
why the charges are not fully covered. 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 10% 
coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities. 
 
You have been asked to pay 10% coinsurance for the parathyroid gland surgery. This item/service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is 
$496.30 ($4,963.02 allowed amount x 10% = $496.30). Therefore, we decided that the Plan does not have to 
waive the coinsurance for the parathyroid gland surgery provided on November 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (procedure code 99223) rendered on July 
3, 2022. 
 
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 Current Procedural Terminology (CPT) code 99223-AI (1 unit) remains 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 99223 is "Initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor 
or unit." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in this case, the documentation 
doesnt support the CPT code 99223. The documentation available for review does not support the encounter 
required decision making of high complexity. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (procedure code 99223) rendered on July 3, 2022.