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

 
We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on 
February 20, 2023. 
 
You asked the Plan to waive the copayment for the physical therapy visit. You say that this should be 
considered a follow-up to a previous procedure. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for the physical therapy visit. This item/service falls within the 
outpatient rehabilitation services 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 
the physical therapy visit provided on February 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter insertion or replacement of permanent 
leadless pacemaker, right ventricular (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker. You say that the enrollee urgently needs a pacemaker. 
The Plan denied your request. The Plan says this device is not covered because there is no documentation 
supporting that the enrollee is participating in an approved CED study. 
 
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are non-covered when 
furnished outside of a CMS approved CED study. 
 
We looked at the file and Medicare rules. The provided documentation does not indicate that the enrollee is 
participating in an approved CED study. Based on this information, we decided that Medicare rules for 
coverage of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-
approve transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular (33274).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Via Disc procedure. 
 
You asked the Plan to pre-approve the procedure. You say that the procedure was recommended for the 
enrollee's nucleus pulposus tissue loss resulting from disc degeneration.  The Plan denied your request. The 
Plan says the Via Disc procedure 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 pre-approve the procedure. Our reviewer says that 
the Via Disc procedure is not medically necessary. Our physician reviewer found the request Via Disc 
procedure is considered and experimental therapy.  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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Via Disc procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp cap (D3120) for tooth #19 provided on December 
13, 2022. 
 
You asked the Plan to pay for the dental service. You say that the pulp cap was necessary and was needed to 
complete the permanent crown. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the pulp cap is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp 
cap (D3120) for tooth #19 provided on December 13, 2022.  
 
Your complaint about your unpleasant experience with the provider 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 pay for procedure code 93971 billed for date of service January 29, 
2023.  
 
You asked the Plan to pay for procedure code 93971. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 93971 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 93971 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 93971 billed for date of service January 29, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug, Hyalgan supartz (J7321). 
 
You asked the Plan to pre-approve drug, Hyalgan supartz . You say that the enrollee has unilateral primary 
osteoarthritis of the left knee. The Plan denied your request. The Plan says the enrollee is unable/unwilling to 
complete physical therapy, and there is no additional information to support medical necessity for drug, 
Hyalgan supartz (J7321). 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug, Hyalgan supartz. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the limited clinical 
documentation does not sufficiently support that Hyalgan is reasonably expected to be safe and effective and is 
medically necessary for the enrollee in this case.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of drug, Hyalgan supartz have not been met. Therefore, we decided that the Plan 
does not have to pre-approve drug, Hyalgan supartz (J7321).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee needs to be admitted into a SNF with 
around the clock care. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary.  
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that 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 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit provided on January 30, 
2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you should not have a copayment. 
The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 there is a $675 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
 
 You have been asked to pay $165 towards your deductible for the office visit. The item or service you asked 
the Plan to waive the deductible for falls within the physician/practitioner services, including doctor's office 
visits benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$675 deductible which applies to physician/practitioner services, including doctor's office visits. This cost 
sharing is a contractual obligation that had not been met at the time the office visit was received on January 30, 
2023. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on 
January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crown - porcelain/ceramic (#19) (D2740) and surgical placement 
of implant body (#29, #30) (D6010). 
 
You asked the Plan to pre-approve dental services. You say that this is medically necessary. The Plan denied 
your request. The Plan says that the dental consultant has determined that the x-ray or photo submitted were not 
of diagnostic value. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide sufficient information to determine if this was 
medically necessary or not. Therefore, we decided that the Plan has to pre-approve crown - porcelain/ceramic 
(#19) (D2740) and surgical placement of implant body (#29, #30) (D6010).  
 
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 home visit evaluation provided on February 17, 2023. 
 
You asked the Plan to pay for the home visit evaluation. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the home visit 
evaluation provided on February 17, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for diagnostic colorectal outpatient surgery. We decided 
that the Plan does not have to waive the copayment for a CT scan.  
 
You asked the Plan to waive the copayment for a diagnostic colorectal outpatient surgery and CT scan provided 
on March 7, 2023.. You say that no polyps were found, and the procedure was billed with the incorrect code. 
The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the copayment for diagnostic colorectal outpatient surgery.  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan charged you a $325 copayment for a diagnostic 
colorectal outpatient surgery stating a risk of perforation caused by adhesions as the reason; However, your 
contract with the Plan does not mention adhesions as a reason for a routine colorectal cancer screening to 
become diagnostic. Therefore, we decided that the Plan has to waive the copayment for diagnostic colorectal 
outpatient surgery.  
 
We also decided that the Plan does not have to waive the copayment for a CT scan. 
 
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 $270 
copayment for a CT scan. The total you owe is $100.39, which is less than the standard copayment for a CT 
scan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a continued SNF stay. You say you believe the enrollee has not exhausted the SNF benefit. The Plan denied 
your request. The Plan says services can be provided other than at an inpatient level of care in a SNF.  
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 25, 2022. 
 
You asked the Plan to pay for the lab services. You say that the testing can assist physicians in decision 
making. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. We looked at the file and Medicare rules. The claim was billed with the laboratory POS code. The records do 
not support that the sample was taken in a laboratory setting. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on November 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on January 13, 2023. 
 
You asked the Plan to pay for the specialist office visit. You say that you were referred by your primary doctor. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the specialist office visit 
provided on January 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting a fast appeal for the denial of a 
SNF admission. You say the enrollee remains appropriate for skilled services and has not returned to baseline. 
The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria for admission to a 
SNF. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 have identifiable skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist; 
however, the enrollee does not require skilled therapy services on a daily basis. The enrollee does not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on January 11, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that the service provided was part of 
the wellness visit. The Plan denied your request. The Plan says this cost sharing was charged 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for the office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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. The record shows that new and chronic conditions 
were discussed that are outside of the wellness visit Therefore, we decided that the Plan does not have to waive 
the copayment for the office visit provided on January 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory test (87631) provided on November 8, 2022. 
 
You asked the Plan to pay for the laboratory test. You say that this test was medically necessary and was 
reported appropriately. The Plan denied your request. The Plan says the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the laboratory test 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory test (87631) 
provided on November 8, 2022.