Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9338) provided February 3, 2021. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim is not eligible for Medicare payment. 

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 code S9338 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, CPT code S9338 is marked with a status of "I" and is not eligible for Medicare payment. Based 
on this information, we decided that Medicare rules for coverage of the home infusion services have not been 
met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9338) provided 
February 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cologuard test to be provided in January 2022.
You asked the Plan to pre-approve the Cologuard test. You say that you cannot tolerate the preparation for a
colonoscopy, which is why you need Cologuard. You also say that you would like to have this done in January
2022 instead of June 2022. The Plan denied your request. The Plan says three years have not passed since your
last Cologuard test. The Plan also says that medical necessity has not been established.
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three
years.
We looked at the file and Medicare rules. The Cologuard test is covered once every three years. The record
shows that you last received a Cologuard test on June 25, 2019, and you cannot receive another Cologuard test
until June 2022. Based on this information, we decided that Medicare rules for coverage of the Cologuard test
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cologuard test to be
provided in January 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessory 
(E0673) provided on April 15, 2021. 
 
You asked the Plan to pay for a pneumatic compression device and accessory. You say that this should be 
considered the industry standard. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a pneumatic compression device (PCD) coded as 
E0675 to treat peripheral artery disease is not eligible for reimbursement. PCD related accessories are eligible 
for reimbursement only when the appropriate, related base PCD meets the applicable coverage criteria for that 
type of PCD.  
 
We looked at the file and Medicare rules. The PCD at issue is not covered. Based on this information, we 
decided that Medicare rules for coverage of a pneumatic compression device and accessory have not been met. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and 
accessory (E0673) provided on April 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available for these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
dental services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied 
your request. The Plan says there is no crown treatment planned in conjunction with this request for core build 
up. The Plan also says that this situation is explicitly not covered per the Evidence of Coverage.
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have not been met. The Evidence of Coverage clearly states that core build up 
must be performed together with a crown. Therefore, we decided that the Plan does not have to pre-approve 
core build up (D2950) for tooth # 5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for future mental health visits. 
 
You asked the Plan to waive the copayments for future mental health visits. You say that you have a limited 
income, and you cannot afford these copayments. The Plan denied your request. The Plan says these 
copayments are a contractual obligation, and they will be charged when you receive services. 
 
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 $25 
copayment per visit for outpatient mental health care.  
 
You have been asked to pay a $25 copayment per visit for future mental health visits. 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 future mental health visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a myocardial perfusion imaging (MPI) test 
(78452) provided on May 6, 2021. We also decided that the Plan does not have to waive the coinsurance for 
regadenoson (J2785) rendered on May 6, 2021. 
 
You asked the Plan to waive the copayment for a myocardial perfusion imaging (MPI) test (78452). You also 
asked the Plan to waive the coinsurance for regadenoson (J2785). You say that you were aware of the 
copayment for the specialist. You also say that no one told you about any fee for the test. 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 $275 
copayment per day, per provider, for in-network, Medicare-covered diagnostic radiology services. Your 
contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B Drugs obtained 
in a provider's office or outpatient setting.  
 
You have been asked to pay a $275 copayment for a myocardial perfusion imaging (MPI) test (78452). 
Myocardial perfusion imaging (MPI) tests (78452) fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. You have also been asked to pay a total of $47.45 in coinsurance, 
which is 20% of the allowed amount for regadenoson (J2785) ($237.24 allowed amount x 20% coinsurance = 
$47.45). Regadenoson (J2785) falls within the Medicare Part B Prescription Drugs 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 a myocardial perfusion imaging (MPI) test (78452) provided 
on May 6, 2021. We also decided that the Plan does not have to waive the coinsurance for regadenoson (J2785) 
rendered on May 6, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the routine electrocardiogram (ECG) (93000) and 
office visit (99215) provided on June 4, 2021. However, we also decided that the Plan does not have to 
completely reduce the cost share to only $40 for these services as requested.  
 
You asked the Plan to reduce the cost share for the ECG and office visit. You say that you paid a $40 specialist 
visit copayment at the time of service and do not understand why these services are this expensive. The Plan 
says that your cost sharing was applied correctly and in accordance with your benefits. Outpatient diagnostic 
procedures and tests require a $150 copayment. 
Documentation shows that the Plan's allowed amount for the office visit was $177.08 and the allowed cost for 
the ECG was $14.34. The Plan assessed a $14.34 copayment for the ECG, and then assessed a $135.66 
copayment for the office visit with a cardiologist, for a total of $150 for both services. 
 
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, and a $40 copayment for an office visit with a specialist. 
 
We decided that the Plan has to reduce the cost share for the office visit with a specialist.  
 
You have been asked to pay a $135.66 copayment for the office visit with a cardiologist. A cardiologist is a 
type of specialist. Based on the Plan contract, however, you cannot be asked to pay more than $40 for an office 
visit with a specialist. Therefore, we decided that the Plan has to reduce the copayment for the office visit with 
a specialist (99215) provided on June 4, 2021.  
 
We also decided that the Plan does not have to reduce the cost share for the ECG. 
 
You have been asked to pay a $14.34 copayment for the ECG. The ECG falls within the diagnostic procedures 
and tests benefit category. The cost of this service is less than the Plan's required copayment, so you are 
responsible for the full allowed amount. This means 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 routine 
electrocardiogram (ECG) (93000) provided on June 4, 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. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services or home with outpatient therapy. 
 
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 enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for revision of a ventriculoperitoneal shunt and was treated for pneumonia. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B chemotherapy
prescription drugs (J0585) provided on June 1, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B chemotherapy prescription drugs. You say
that the coinsurance should be less or $0. The Plan denied your request. The Plan says the coinsurance 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%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for Medicare Part B chemotherapy prescription drug (20% of
$1,212 = $242.40). 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 coinsurance for Medicare Part B chemotherapy
prescription drugs (J0585) provided on June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pay for the $100 rental of a wheelchair on vacation on April 24, 2021. 
 
You asked the Plan to pay for these rental fees. You say that you were on vacation and needed to use the 
wheelchair while you were away due to some broken bones. The Plan denied your request. The Plan says 
durable medical equipment for vacation purposes is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The Plan contract states that durable medical equipment requires prior 
authorization. This equipment was used away from your home. You did not have prior authorization.  
Although this item may have been helpful for you to use on vacation, neither Medicare nor the Plan covers 
equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the $100 
rental of a wheelchair on vacation on April 24, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can continue to be met in a skilled nursing facility setting.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgery for ileostomy takedown. He was discharged to skilled nursing on September 22, 2021 and to assisted living facility on October 8, 2021. There is ongoing weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan has to pay for air ambulance and ground ambulance transportation provided on 
October 30, 2020. 
 
You asked the Plan to pay for ambulance services. You say that this transport was needed so the enrollee could 
receive hospice services with her family, but the financial burden is significant. The Plan denied your request. 
The Plan says that these services were not medically necessary. 
 
The Plan follows Medicare rules. Medicare pays for ambulance services only when they are medically 
reasonable and necessary. Medicare pays for air ambulance services only if the enrollee's medical condition is 
such that transportation by ground ambulance is not appropriate.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ambulance services. Our reviewer says that 
these services meet the Medicare criteria for coverage. Our physician reviewer found the enrollee had end stage 
metastatic carcinoma with altered mental status noted on her medical records due to brain metastases and pain 
control medication. She required medical monitoring of her vitals and would not be stable for transport in a 
non-medical vehicle. The enrollee's condition contraindicated transportation by any means other than 
ambulance, and for the air ambulance portion of the trip the enrollee's condition was such that the time needed 
to transport the enrollee by ground, or the instability of transport by ground, posed a threat to the enrollee's 
survival or seriously endangered the enrollee's health. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance services have been met. Therefore, we decided that the Plan has to 
pay for air ambulance and ground ambulance transportation provided on October 30, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an annual health club membership provided on January 1, 2020.
You asked the Plan to reimburse you for an annual health club membership. You say that there should be no deadline for reimbursement requests due to Coronavirus, and it should have been extended. The Plan denied your request. The Plan says you submitted your reimbursement for your 2020 Wellness Allowance after the March 31st deadline. Additionally, the Plan extended the deadline to April 30, 2021, due to Coronavirus and that deadline was missed as well.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because your Wellness Allowance reimbursement request was not submitted by the Plan's benefit deadline. Therefore, we decided that the Plan does not have to reimburse you for an annual health club membership provided on January 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no need for medical monitoring by a rehabilitation doctor.
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 enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for weakness. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
supports a need for physical and/or occupational therapy, there is no documented need for intensive
rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee