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

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the radiologist has recommended a 
CT scan for further evaluation of a pulmonary nodule in your left lung and your primary physician deemed it 
medically necessary that the nodule be further evaluated with a CT scan. The Plan denied your request. The 
Plan says a LDCT scan for lung cancer screening is not medically necessary. The records support the medical 
necessity criterion for a diagnostic CT. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the low dose CT scan. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found certainly a 1 cm pulmonary nodule is in need of CT evaluation. However, a low dose 
lung cancer screening test is not the appropriate exam. Such a scan is reserved for asymptomatic patients who 
fulfill the smoking criteria for CMS.  This case involves the analysis of an abnormal finding seen on a different 
exam for which a diagnostic CT, CPT 71250 would be appropriate. 
 
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 low dose CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a punch biopsy of skin (11104) provided on 
July 19, 2021. 
 
You asked the Plan to waive the copayment for the punch biopsy of skin. You say that the services should be 
covered in full as you were not made aware of the copayment beforehand. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Medicare-covered ambulatory surgical center visits. 
 
 
 
 
 You have been asked to pay a $250 copayment for the punch biopsy of skin. Punch biopsies of skin fall within 
the Physician/Practitioner services, including doctors office visits benefit category, specifically Medicare-
covered ambulatory surgical center 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 copayment for a punch 
biopsy of skin (11104) provided on July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shoulder arthroscopy; with rotator cuff repair (29827), 
the shoulder surgical debridement (29823), the implantable anchors/screws (C1713 x 2), the adrenalin, 
epinephrine injection (J0171), and the surgical supplies (A4649) rendered by the out-of-network (OON) 
provider on October 25, 2021. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the items/services were rendered by an 
out of network provider, without prior authorization. 
 
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 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 
items/services 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 shoulder arthroscopy; with rotator cuff repair 
(29827), the shoulder surgical debridement (29823), the implantable anchors/screws (C1713 x 2), the adrenalin, 
epinephrine injection (J0171), and the surgical supplies (A4649) rendered by the out-of-network (OON) 
provider on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator 
is medically necessary as the tanks you have are cumbersome or heavy when used outside shopping or in the 
park. The Plan denied your request. The Plan says you currently have oxygen equipment for use in the home. 
 
The Plan must follow Medicare rules. Medicare does not cover duplicate equipment or equipment for outside 
of the home. The file shows that you have oxygen equipment for use in the home. This equipment services the 
same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-
approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941). 
 
You asked the Plan to pre-approve the chiropractic treatment. You say that please revise the prior authorization 
denial as this is again a medically necessary condition and incident with appropriate treatment. The Plan denied 
your request. The Plan says the enrollee has reached maximum therapeutic benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance 
care.  
 
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 chiropractic treatment. Our reviewer 
says that the records do not support that the requested services is medically necessary for the enrollee in this 
case. Our physician reviewer found in this case the record indicates that the enrollee has spinal subluxations. 
The provided records do not indicate that there is expectation of improvement but rather that a maintenance 
phase has been reached. The enrollee has one to two treatments per month. The record does not document 
objective improvement and does not support a worsened chronic condition. The elements of the coverage 
criteria are not satisfied, and the requested service is not recommended. 
 
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 chiropractic treatment have not been met. Therefore, we decided that the 
Plan does not have to pre-approve chiropractic manipulative treatment (98941).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services (86235) provided on 
March 23, 2021. 
 
You asked the Plan to waive the copayment for the laboratory services. You say that the services should be 
covered in full. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the 
services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
 
 
 You have been asked to pay a $15 copayment for laboratory services. Laboratory services fall within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services (86235) provided on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan 
states it is not safe for the enrollee to leave the hospital at this time because the enrollee has a feeding tube 
through their nose. The Plan states the enrollee is receiving the care they need in the hospital where they are 
now and there is no need to transfer to the LTACH at this time. The Plan states the enrollee can stay in the 
hospital until they are safe for transfer or discharge. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to not be improving and requires only short-term additional 
acute care services that can safely be administered at the current facility. The patient does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. Transfer to LTACH is not 
medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be 
considered when treatment is completed.  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out-of-
network (OON) provider on September 2, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the laboratory service (88305) rendered by the out-of-network (OON) provider on 
September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on September 29, 2021. 
 
You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 laboratory services rendered by the out-of-network (OON) provider on 
September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150). We decided that the Plan 
does not have to pay for the diagnostic procedure (D0999).  
 
You asked the Plan to pay for the comprehensive oral evaluation (D0150) and diagnostic procedure (D0999). 
You say that the dental office told you that everything would be covered which is why you went ahead with the 
services. You also say that you would like this appeal to be approved because you cannot afford to pay for 
these services. The Plan says that these services are not covered. 
 
We decided that the Plan has to pay for the comprehensive oral evaluation (D0150).  
 
The Plan follows Medicare rules. Medicare rules say that the health plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits. 
 
The file shows that you received a comprehensive oral evaluation (D0150) on November 29, 2021. The Plan 
did not provide the applicable 2021 Evidence of Coverage for this case, but did provide the 2021 Summary of 
Benefits which states that you are allowed 1 oral exam every 12 months. The Plan also provided the 2021 
Office Reference Manual which states you are limited to two of the following codes D0120, D0150, or D0160, 
per 12 months. These contracts submitted by the Plan do not show the same limitations for this service. The 
Plan says that you have exhausted your exams benefit for the 2021 Plan year, however, no documentation was 
provided showing this benefit has been exhausted, and with the conflicting contract information it cannot be 
determined whether you are allowed 1 oral exam or 2 oral exams per 12 months. Therefore, we decided that the 
Plan has to pay for the comprehensive oral evaluation (D0150).  
 
We also decided that the Plan does not have to pay for the diagnostic procedure (D0999). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
diagnostic procedure (D0999). 
 
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 pay for the inpatient psychiatric hospital care rendered by the out-of-
network (OON) provider from October 16, 2021, through October 20, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
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 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 inpatient psychiatric hospital care rendered by the out-of-network (OON) 
provider from October 16, 2021, through October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the 
enrollee is ambulating at baseline and is able to perform activities of daily living independently. The Plan also 
says that the services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for IV infusion therapy provided from July 
15, 2021, to July 27, 2021. 
 
You asked the Plan to waive the copayments for IV infusion therapy. You say that you were not told about the 
charges ahead of time and disagree with them. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 You received IV infusion therapy at an outpatient hospital facility from July 15, 2021, to July 27, 2021, for a 
total of 13 visits. Because you received services in an outpatient hospital facility you are responsible to pay the 
allowed amount of $245.84, which is less than the total copayment amount, per each visit. The total amount 
you owe is: $245.84 (allowed amount) x 13 (IV infusion therapy services) = $3,195.92.  
 
You have been asked to pay the total copayment amount of $3,195.92 for IV infusion therapy. IV infusion 
therapy falls within the outpatient surgery and other medical services provided at hospital outpatient facilities 
and ambulatory surgical centers 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 copayments for 
IV infusion therapy provided from July 15, 2021, to July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the hip (73502) rendered by the out-of-
network (OON) provider on October 22, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the x-ray exam of the hip (73502) rendered by the out-of-network (OON) provider on 
October 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of abdomen and pelvis 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request does not meet medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the notes describe a plan 
for the enrollee to be evaluated in the office after the CT which is inappropriate. In addition, as the constipation 
is a recurring problem, there is no record of a recent colonoscopy. As there are no red flags to suggest 
immediate CT without a physical exam, the medical necessity of the CT has not been established. 
 
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 scan have been met. Therefore, we decided that the Plan does not have to 
pre-approve computed tomography (CT) scan of abdomen and pelvis for the enrollee.