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

 
We decided that the Plan does not have to pre-approve community-based adult services (CBAS) for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says care needs do not support for a need for being at adult day health care. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is not shown to have any acute medical nursing or therapy needs. The requested services 
appear to be custodial.  As such, the requested services are not medically necessary, reasonable or coverable. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve community-based adult services (CBAS) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not paid separately. 
 
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 99100 is "Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." 
 
 We find that CPT code 99100 is not supported in the case file. Specifically, this code has a status indicator of B 
according to the Medicare Physician's Fee Schedule. This means that payment for this service is bundled into 
payment for other codes, and this code cannot be billed separately. 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 anesthesia services provided to the enrollee on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99215) provided on December 7, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that both the doctor and the facility are contracted with 
the Plan. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and 
they have also determined that these services are not urgent or emergent, nor were they approved in advance. 
The Plan also says that they verified via phone that there was no referral on file and spoke with the primary 
care physician's office on February 4, 2022, to verify the member was not referred to this 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 an office visit (99215) provided on December 7, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) 
joint. 
 
You asked the Plan to pre-approve RFA of the SI joint. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve RFA of the SI joint. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is considered an experimental/investigational procedure due to the wide variation 
in efficacy reported in the peer reviewed literature. Therefore, the request is deemed not medically reasonable 
or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of RFA of the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the 
sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay further reimbursement for equipment and supplies purchased out 
of network on October 20, 2021. 
 
You asked the Plan to pay additional reimbursement. You say that you paid $1099 for this equipment, and you 
expect the Plan to pay for this in full. The Plan denied your request. The Plan says you were reimbursed the 
Medicare allowable amount for this equipment in the amount of $532.35 and $59.15 totaling the allowed 
amount of $591.50.  
 
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 durable medical equipment 
requires prior authorization. Plans can only pay for services in the amounts that are allowed or covered by 
Medicare. Network providers have agreements with Plans to accept the Medicare allowable payment. Out of 
network providers cannot be compelled by the Plan to reimburse you for any amount paid over the Medicare 
allowable. If the out of network provider typically accepts Medicare payment, they should be reimbursing you 
for the difference between what you paid out of pock and the Medicare allowable paid by the Plan. Therefore, 
we decided that the Plan does not have to pay further reimbursement for equipment and supplies purchased out 
of network on October 20, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department service (99285) provided on 
October 25, 2020. 
 
You asked the Plan to pay for the emergency department service. You say that you would like this claim 
reprocessed. The Plan denied your request. The Plan says this claim has not been filed within timely filing 
limits. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency department service was not filed until January 5, 2022. This 
means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the emergency department service (99285) 
provided on October 25, 2020.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for in-network outpatient hospital services, totaling 
$1,576.40. We decided that the Plan does has to reduce the charge to the correct $195 copayment for in-
network outpatient hospital services. You asked the Plan to waive the coinsurance for in-network outpatient hospital services, totaling $1,576.40. 
You say that you should not be held responsible for the charges. The Plan says that the coinsurance amount 
charged is correct. 
 
We decided that the Plan has to waive the coinsurance for in-network outpatient hospital services, 
totaling $1,576.40 .  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $195 copayment for in-network outpatient hospital 
services. In-network outpatient hospital services fall within the Outpatient Hospital Services benefit category. 
 
The Plan says you must pay 25% coinsurance, totaling $1,576.40. Based on the Plan contract, however, you 
cannot be asked to pay more than a $195 copayment for an in-network outpatient hospital services. Therefore, 
we decided that the Plan has to reduce the copayment for in-network outpatient hospital services from 
$1,576.40 to $195.  
 
 We also decided that the Plan has to reduce the charge to the correct $195 copayment for in-network 
outpatient hospital 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 $195 
copayment for in-network outpatient hospital services. Therefore, we decided that the Plan has to reduce the 
charge to the correct $195 copayment for in-network outpatient hospital services. 
 
 
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 pre-approve repeat endobronchial valve placement. 
 
You asked the Plan to pre-approve repeat endobronchial valve placement. You say that this is medically 
reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 
requested Bronchoscopy is not medically reasonable and necessary at this time. 
 
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 repeat endobronchial valve placement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found Repeat endobronchial valve placement is considered not medically 
necessary. This patient has severe chronic obstructive pulmonary disease (COPD) with hyperinflation and had 
endobronchial valve (EBV) placement to the right upper lobe and right middle lobe on September 22, 2022. It 
appears that there was no benefit to this procedure. A follow-up chest computed tomography scan showed 
minimal or no volume loss in the treated lobes, suggesting that valve occlusion was unsuccessful. The reason 
for the failure of the first procedure is unclear; it could include poor valve positioning, or other causes, 
including lack of fissural integrity.  EBV has been shown in controlled clinical trials to be effective in improving symptoms, functional status, and 
pulmonary physiology in selected patients with emphysema.  However, it is not clear whether there are benefits 
of a repeat procedure that outweigh the risks in patients who have failed a prior EBV placement. The denial is 
upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat endobronchial valve placement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve repeat endobronchial valve placement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic procedure (97110) provided November 11, 2021. 
 
You asked the Plan to pay for the chiropractic service. You say that this should have been paid for the service 
you received. The Plan denied your request. The Plan says this service is not covered when rendered by a 
chiropractor. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapeutic procedure (97110) provided November 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing of 51 or more genes provided on August 3, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the testing is not medically necessary, 
 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this cannot be approved unless the non-small cell lung cancer is metastatic. There is no evidence of 
recurrence. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for genetic testing of 51 or more genes provided on August 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 8, 2021, to April 
10, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was an emergency admission via 
ambulance. The Plan denied your request. The Plan says that the requested inpatient care is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the provided documentation indicates that at the time of inpatient admission the admitting 
physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from April 8, 2021, to April 10, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee. 
 You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the member has not been treated with intra-articular corticosteroid injection 
therapy. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via 
intra-articular injections of hyaluronic preparations can be covered if the Medicare criteria has been met. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One is not considered medically reasonable and necessary in this case. The medical records do not 
document that the patient has failed at least three months of conservative therapy (home exercise program, 
education, weight loss, physical therapy if indicated), or has failed to respond to aspiration of the knee when 
effusion is present, or a trial of intra-articular corticosteroid injections. There is no documentation of 
contraindication to steroid therapy. The clinical value and effectiveness of viscosupplementation in the setting 
of knee osteoarthritis without a trial of intra-articular corticosteroids has not been demonstrated in the peer-
reviewed literature. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for Synvisc-One. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy (90837, 90832) provided on April 14, 2021, 
to April 25, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says this was denied due to no prior authorization for dates of services April 14, 
2021, to April 25, 2021, and they did not authorize any services for this provider. The Plan also says that the 
rendering provider is a non-participating provider, and there is no referring provider involved in 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 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 psychotherapy (90837, 90832) provided on April 
14, 2021, to April 25, 2021, by an out-of-network (OON) provider.  
 
Your complaint about the potentially poor customer service and their accessibility to submit claims is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a colorectal cancer screening colonoscopy 
provided on August 24, 2021. 
 
You asked the Plan to waive the coinsurance for the colorectal cancer screening colonoscopy. The Plan denied 
your request. The Plan says the claim was processed 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 45% 
coinsurance for Colorectal cancer screening, Out-of-Network Specialist's Office, Ambulatory Surgical Center, 
Outpatient Hospital.  
 
 You have been asked to pay a 45% coinsurance for the colorectal cancer screening colonoscopy. The colorectal 
cancer screening colonoscopy falls within the Colorectal Cancer Screening, Out-of-Network Specialist's Office, 
Ambulatory Surgical Center, Outpatient Hospital 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 
coinsurance for a colorectal cancer screening colonoscopy provided on August 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an eptinezumab (VYEPTI) injection 
provided on December 10, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you have a company that covers the 
cost of the medication. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 Part B drugs.  
 
You have been asked to pay $938.10, which is 20% of the allowed amount for the injection ($4,690.50 allowed 
amount x 20% coinsurance = $938.10). The injection falls within the Medicare Part B Prescription Drugs 
benefit category. Please note that the Plan is not responsible for any third party assistance. You can reach out to that company for information on how to be reimbursed for the costs. 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 an eptinezumab (VYEPTI) injection provided on December 10, 2021.