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

We decided that the Plan has to pre-approve hemodialysis services to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that there are in-network providers available to 
render the requested 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 for covered services that are 
medically necessary. Additionally, the provider must be eligible to participate in Medicare.  
 
The requested provider in this case is not a network provider with the Plan. However, the Plan contract states 
that as a member of the Plan, you can receive your care from an out-of-network provider that is eligible to 
participate in Medicare. Therefore, we decided that the Plan has to pre-approve hemodialysis services to be 
rendered by the out-of-network (OON) provider.  
 
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for behavioral health telehealth services provided from April 1, 2021, to May 10, 2021.
You asked the Plan to waive the copayments for the behavioral health telehealth services. You say that you were never told about a copayment for mental health telehealth visits. The Plan denied your request. The Plan says it originally processed these claims incorrectly. The Plan states that due to incorrect information provided to you by the Plan, they have reprocessed these claims so that only a $35 copayment per date of service has been charged.
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 $40 copayment for each mental health visit.
You have been asked to pay a $40 copayment for the behavioral health telehealth services. The behavioral health telehealth services fall within the mental health visit 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 behavioral health telehealth services provided from April 1, 2021, to May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 18, 2021.
You asked the Plan to reimburse you for hearing aids. You say that you believe it is cost effective. The Plan denied your request. The Plan says you must use the Plan's hearing provider and the Plan has not received a receipt showing proof of payment.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pay for the myocardial perfusion imaging (78452), heparin sodium injection
(J1642), rhythm ECG (93040), cardiovascular stress test (93015), technetium tc-99m (A9502). We decided that
the Plan does not have to pay for the introduction of needle or intracatheter (36000) and therapeutic injection
(96374).
You asked the Plan to pay for the services billed. The Plan says that an appropriate modifier was not billed with
this code edit.
We decided that the Plan has to pay for the myocardial perfusion imaging (78452), heparin sodium
injection (J1642), rhythm ECG (93040), cardiovascular stress test (93015), technetium tc-99m (A9502).
The Plan has not provided sufficient information to determine why CPT codes 78452, 93040, 93015 and
A9502 do not meet criteria for billing or reimbursement consideration. Of note, the Plan has denied CPT code
J1642 stating that an edit exists with CPT code 78452, but an edit does not exist between CPT code J1642 and
78452. The Plan has not submitted any documentation to support a denial of CPT codes 93040, 78452, 93015
and A9502. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not
been supported so we must find in your favor. Therefore, we decided that the Plan has to pay for the
myocardial perfusion imaging (78452), heparin sodium injection (J1642), rhythm ECG (93040), cardiovascular
stress test (93015), technetium tc-99m (A9502).
We also decided that the Plan does not have to pay for the introduction of needle or intracatheter
(36000) and therapeutic injection (96374).
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 36000
and 96374 is a column II code to column I code 78452. 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 the introduction of needle or intracatheter (36000)
and therapeutic injection (96374).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on March 2, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the requested services were medically
necessary. The Plan denied your request. The Plan says the documentation does not support that the coverage
criteria have been met.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with
the primary or attending physician or the attempt to make such a consultation.
We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or
attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage
of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for
the psychotherapy services provided on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cardiac catheterization you received on
June 7, 2021.
You asked the Plan to waive the cost sharing for the cardiac catheterization. You say that you are on a fixed
income and it is not fair that you are being charged this much for this medically-necessary service. The Plan
denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that at the time
of the services, you had not yet met your annual deductible. You were assessed the deductible of $246. After
the deductible was satisfied, you were charged coinsurance appropriately on the remainder.
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 $246
deductible for outpatient procedures.
Once the deductible is met, you pay 10% coinsurance for outpatient surgery and other services at an outpatient
hospital.
You have been asked to pay a $246 deductible, and once met, 10% coinsurance on the remaining cost, for the
cardiac catheterization. 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 cost sharing for the cardiac catheterization you
received on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a complete ultrasound scan behind the 
abdominal cavity (76770) provided on January 19, 2021. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you should not be responsible for 
the copayment because the claim was not accurate. The Plan denied your request. The Plan says all billed 
services were recorded on your medical chart from the provider. 
 
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 if diagnostic services 
are performed in an office visit, the greater of an office visit or diagnostic service copayment will apply.  
You must pay a $70 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. 
  
You have been asked to pay a $70 copayment for the ultrasound. Since $70 for the diagnostic service is greater 
than the $0 copayment for the office visit, 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 complete 
ultrasound scan behind the abdominal cavity (76770) provided on January 19, 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. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia provided on March 12, 2021. 
 
You asked the Plan to pay for the anesthesia. You say that you would like this claim to be reprocessed for 
payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of 
all Medicare covered services related or unrelated to the enrollee's terminal condition. 
 
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 anesthesia provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not use insulin in any form. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. 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 a continuous glucose 
monitor
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan has to pre-approve a Mirena intrauterine device (IUD). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has excessive and frequent 
menstruations with irregular cycle. The requested Mirena is being used for these diagnoses and not for 
contraceptive purposes. Mirena is FDA-approved for the use of heavy menstrual bleeding. The records support 
that the requested Mirena IUD is reasonable and medically necessary and safe and effective to treat the 
enrollee's medical diagnoses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve a Mirena intrauterine device (IUD).  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 laboratory services provided on October 15, 
2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the rules for LTACH care have not been met.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the head or brain without contrast (70450) provided on July 7, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you feel you are not liable for this cost-share because the copayment listed on your insurance card for emergency room is $90. The Plan denied your request. The Plan says when advanced imaging services, which includes CT scans, are provided in an emergency department, you only pay the advanced imaging copayment, not the emergency room copayment.
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 $225 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay a $225 copayment for a CT scan. CT scans 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 a Computed Tomography (CT) scan of the head or brain without contrast (70450) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services rendered on April 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 11721, 11056, and 99307 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 11721 is debridement of nail(s) by any method(s); 6 or more. The definition of code 11056 is paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions. The definition of code 99307 is subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components. We find that CPT codes 11721, 11056, and 99307 are not supported in the medical record. Specifically, there is no documentation of debridement of 6 or more nails to support code 11721. There is no documentation of paring or cutting of benign lesions to support code 11056. There is no documentation of subsequent nursing facility care to support code 99307. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry services rendered on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, and 81355 provided on April 20, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 codes 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, and 81355 are not supported in the medical record. Specifically, the services rendered are not specifically satisfactorily described by any existing code; therefore, should be coded 81479 used for the entire bundled multi-test panel). In addition, the appropriate DEX-Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81335, and 81355 provided on April 20, 2021.