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

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee needs this device due to her 
worsening heart failure. The Plan denied your request. The Plan says the device has been determined to be of 
uncertain value. 
 
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 requested device. Our physician 
reviewer found that the enrollee has recurrent congestive heart failure (CHF). The CardioMEMS device allows 
measurement of pulmonary artery pressure in the management of those with CHF. The clinical study on which 
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. In addition, published expert opinion in the cardiology literature is supportive of 
the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth 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 enrollees 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 requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from October 13, 2021, to 
November 2, 2021. 
 
You asked the Plan to pay for the home health services. You say that you sent paper claims. You also say that 
the system does not allow you to take these claims out and send them separately. The Plan denied your request. 
The Plan says the RAP claim was not received until December 28, 2021, more than 5 days after the start of 
care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, October 13, 2021. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from October 13, 2021, to November 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 16, 2021. 
 
You asked the Plan to pay for the services provided on December 16, 2021.. You say that the service was 
medically necessary. The Plan denied your request. The Plan says this provider is on the opt-out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services provided on December 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on October 3, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you feel 
you saved the Plan money by not being transported to the hospital. The Plan denied your request. The Plan says 
your plan covers ambulance transportation only when you are actually transported by ambulance. The Plan also 
says that since you were not transported by ambulance, the service is not covered by your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on October 3, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on October 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit, hot/cold pack application, and chiropractic 
manipulative treatment provided by a chiropractor on January 4, 2022. 
 
You asked the Plan to pay for chiropractic services. You say that you were under the impression that the $20 
copayment covered the cost of this visit. The Plan denied your request. The Plan says the denial of payment for 
the office visit and hot/cold pack application is correct, because these services are not covered when performed 
by a chiropractor. The Plan also says that the copayment amount you are being charged is correct. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 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 copayment for covered chiropractic services. 
 
The records show that the office visit and hot/cold pack therapy services at issue are not manual manipulation 
of the spine. Additionally, you have been asked to pay $20 copayment for the covered chiropractic 
manipulative treatment. Chiropractic services fall within the Chiropractic Service 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 pay for an office visit, hot/cold pack application, and chiropractic manipulative treatment 
provided by a chiropractor on January 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve the requested item. You say that you need a comfortable bed to ensure you 
can breathe comfortably. The Plan denied your request. The Plan says neither Medicare nor your plan covers a 
total electric hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
We looked at the file and the rules. While a total electric hospital bed may be appropriate in this case, neither 
the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-
approve a total electric hospital bed.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 16, 2021, to 
August 14, 2021, and from September 14, 2021, to October 11, 2021. 
 
You asked the Plan to pay for the home health services. You say that these claims were originally submitted 
with Generic Health Insurance Prospective Payment System (HIPPS) codes which you have corrected. The 
Plan denied your request. The Plan says the non-contracted provider did not submit the RAP claim for services 
for date of service July 16, 2021, to August 14, 2021 until September 2, 2021, and did not submit a RAP claim 
for services September 14, 2021, to October 11, 2021. 
 
  The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care dates, July 16, 2021, and September 14, 2021. Therefore, 
we decided that the Plan does not have to pay for the home health services provided from July 16, 2021, to 
August 14, 2021, and from September 14, 2021, to October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crown (D2740) provided on November 29, 2021. 
 
You asked the Plan to pay for the crown. You say that your crown was broken, you had open nerves, and this 
service should be covered. The Plan denied your request. The Plan says that the Health Plan will not authorize 
payment for dental services received from a non-participating or non-network provider. The Plan also says that 
you received self-referred services from a provider that is not a Plan participating provider. 
 
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. The Plan did not provide a copy of the applicable 2021 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the crown (D2740) provided on November 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.
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. The Plan denied your request. The Plan says you do not need an 
intensive team for 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 physician reviewer found 
that you were admitted to the acute care hospital for a small bowel obstruction. Your medical problems are 
stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infusion supplies and milrinone lactate provided from 
September 17, 2021, to September 22, 2021. 
 
You asked the Plan to pay for the infusion services. You say that the claim has not been paid per the terms of 
the contract. The Plan denied your request. The Plan says the enrollees claim would be covered under Original 
Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of 
the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the 
enrollees coverage before rendering services and to know proper billing procedures for a Medicare Advantage 
member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the infusion supplies and milrinone lactate provided from 
September 17, 2021, to September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99335), provided on December 21, 2021 by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
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 the office visit 
(99335), provided on December 21, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation services. 
 
You asked the Plan to pre-approve radiofrequency ablation services. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation of cervical, thoracic, or 
lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for 
patients who have had at least two (2) medically reasonable and necessary diagnostic medial branch blocks 
(MBBs). 
 
We looked at the file and Medicare rules. In this case, the documentation confirms that only one MBBs was 
performed on March 11, 2022. Based on this information, we decided that Medicare rules for coverage of 
radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-
approve radiofrequency ablation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2750) provided on October 26, 2021. 
 
You asked the Plan to pay more for the crown (D2750). You say that you paid everything you were supposed 
to but received a new bill. You say that you want help paying the difference. The Plan denied your request. The 
Plan says you met the benefit maximum of $1,000 per year with the processing of this claim. 
 
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, you also have a maximum benefit of 
$1,000 per calendar year for covered dental services. The Plan paid $97.20 toward the crown provided October 
26, 2021, which met your $1,000 maximum. You are responsible for the remaining cost. Therefore, we decided 
that the Plan does not have to pay more for the crown (D2750) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two precision attachments (D5862 x2). 
 
You asked the Plan to pre-approve the precision attachments. You say that you cannot be left with the two 
implants you have unless a permanent denture is made to fit onto them. The Plan denied your request. The Plan 
says this service is not covered on your plan. 
 
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 pre-approve two 
precision attachments (D5862 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient mental health hospital stay 
provided from September 2, 2021, to September 10, 2021. 
 
You asked the Plan to waive the copayment for an inpatient mental health hospital stay. 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 $150 
copayment per day for days 1-7 for an inpatient mental health hospital stay. The contract also says that there is 
a $0 copayment per day for days 8-90. 
 
 You have been asked to pay a total of $750, which is less than the $150 copayment per day for days 1-7 for an 
inpatient mental health hospital stay from September 2, 2021, to September 10, 2021. There is no charge for 
days 8-90. There is also no charge for the day of discharge. An inpatient mental health hospital stay falls within 
the Inpatient Mental Health 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 
an inpatient mental health hospital stay provided from September 2, 2021, to September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70480 billed for date of service September 
14, 2021. 
 
You asked the Plan to pay for procedure code 70480. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70480 is bundled into payment for 
code 70450. 
 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 70480 
is a column II code to column I code 70450. 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 procedure code 70480 billed for date of service September 14, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
 
 
 
 
 
 
 The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on October 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy services (97110, 
97014, 97161) provided on January 26, 2022. 
 
You asked the Plan to waive the copayment for the physical therapy services. You say that you would like 
reconsideration because you were referring for physical therapy and this should be covered. The Plan denied 
your request. The Plan says the cost sharing has been applied 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 $20 
copayment for Outpatient Rehabilitation.  
 
You have been asked to pay a $20 copayment for the physical therapy services. Physical Therapy falls within 
the Outpatient Rehabilitation 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. 
 Of note, the Plan has confirmed that you are not being held liable for the denied service. You are only 
responsible for the applicable copayment in this case. Therefore, we decided that the Plan does not have to 
waive the copayment for the physical therapy services (97110, 97014, 97161) provided on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy services. 
 You asked the Plan to pre-approve proton beam therapy services. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim 
represents a cost that is associated with a clinical trial and is not covered by the Plan. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve proton beam therapy services as part of a clinical trial. The Plan 
does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does 
not have to pre-approve proton beam therapy services.