Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 9, 2020. 
 
You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says you must use a 
Plan hearing aid provider to use the hearing aid benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by the Plan's hearing aid provider. 
 
We looked at the file and the Plan's rules. The Plan 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 the 
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 8. 
 
You asked the Plan to pre-approve the dental service. You say that the core build up is necessary to the services 
rendered. The Plan denied your request. The Plan says core build up is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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 pre-approve core 
build up (D2950) for tooth # 8.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 30, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says there were not medical records submitted to support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and provide records to support the services billed.  
In this case, there were insufficient medical records or testing results provided to support the services billed. 
The ordering physician is out of network and therefore the Plan has no control over the records that would 
document the reason for the testing ordered. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on 
December 3, 2019. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 80307 and G0482 are not supported in the medical record. Specifically, the 
documentation does not contain evidence of an established relationship between the ordering physician and the 
enrollee. Based on this information, we decided that Medicare rules for coverage of the drug testing have not 
been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and 
G0482 provided on December 3, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve shoulder surgery for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the requested surgery is supported when there have been detailed picture studies 
showing a problem in the shoulder which matches the reported symptoms, and the results of an examination by 
the doctor. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with persistent and significant left lateral shoulder pain. Pain interfered with 
function and disrupted her sleep. Left shoulder exam documented positive impingement and biceps tendon 
signs. There is imaging evidence of a high-grade partial thickness bursal sided rotator cuff tear and rotator cuff 
tendinosis. She has failed reasonable and/or conservative treatment, including activity modification, 
medications, physical therapy, home exercise program, and subacromial injection. Authorization was requested 
for left shoulder arthroscopy with debridement, possible rotator cuff repair/augmentation, biceps tenodesis, and 
acromioplasty. The request for biceps tenodesis has been denied as there was no imaging evidence of biceps 
pathology and biceps tenodesis is not supported over biceps tenotomy in this enrollee's age group. Current 
evidence based medical literature supports the use of either biceps tenodesis or biceps tenotomy for long-head 
biceps tendon lesions with concomitant reparable rotator cuff tears. Occult biceps tears, incomplete and MRI-
negative are often confirmed at time of arthroscopic surgery. Biceps tenodesis is reasonable based on the 
discretion of the surgeon at the time of arthroscopic evaluation and concomitant rotator cuff repair. Therefore, 
this request would be considered medically reasonable and 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 the surgery have been met. Therefore, we decided that the Plan has to pre-
approve shoulder surgery for the enrollee.  
 
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: Favorable

 
We decided that the Plan has to pay for the infectious agent detection (87631) provided on June 15, 2020. 
 
You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says that respiratory infectious agent 
detection, code 87631, is non-covered by Medicare and is excluded from coverage. 
 
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 CPT code 87631 is listed as a 
covered code in Medicare's Local Coverage Article: Billing and Coding: MolDX: Multiplex Nucleic Acid 
Amplified Tests for Respiratory Viral Panels (A56851). 
 
We find that CPT code 87631 is supported in the record. Specifically, Medicare's pertinent LCD indicates that 
this code is covered. Based on this information, we decided that Medicare rules for coverage of the infectious 
agent detection have been met. Therefore, we decided that the Plan has to pay for the infectious agent detection 
(87631) provided on June 15, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heel lift for the enrollee. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is needed due to leg-length discrepancy. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a heel lift for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantable neurostimulator electrode (CPT Code 
L8680) and percutaneous implantation of neurostimulator electrode array, epidural (63650). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says your request is not medically necessary because the records show this is not a late or last 
resort. The Plan states there is no surgical evaluation has been provided and no other prior pain treatments, 
other than epidural steroid injections, have been tried. 
 
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 physician reviewer 
found in this case, the member has been referred for SCS trial for management of chronic pain. Some of the 
member's chronic pain involves their low back. (The member also has a history of chronic knee pain). 
According to the applicable LCD/NCD, a SCS device may only be covered when used as a "last resort". More 
specifically the coverage guidelines state: "other treatment modalities (pharmacological, surgical, physical, or 
psychological therapies) have been tried and did not prove satisfactory, or are judged to be unsuitable or 
contraindicated for the given patient". In this case there was no documentation provided showing that the 
member met all of these requirements. There was no indication of a surgical consult/evaluation or that the 
member had prior surgery. Consequently, it cannot be determined that SCS would be the therapy of last resort. 
In as much this service would not meet the requirements for coverage. 
 
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 implantable neurostimulator electrode (CPT Code L8680) and percutaneous implantation 
of neurostimulator electrode array, epidural (63650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this level of care exceeds medical need. 
 
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short term acute 
care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
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 admission to a long term acute care hospital (LTACH)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to pay for 
 
You asked the Plan to pay for supply codes defined by A5501 and A5513. You say that the claim should be 
paid. The Plan denied your request. The Plan says the documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service.  
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery and relevant medical records which support medical 
necessity for the supplies provided in this case. The documentation submitted did not include an itemized 
shipping/billing invoice to indicate the specific supplies, or proof of delivery for the billed date of service. 
Therefore, the billed code cannot be verified.  The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. 
 Therefore, we decided that the Plan does not have to pay for to pay for
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services 
provided on September 14, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees 
must pay $90 copayment for emergency room services. You have been asked to pay the correct amount based 
on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the $90 copayment charged for emergency 
room services provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the prefabricated post and core (D2954). 
 
You asked the Plan to pre-approve the prefabricated post and core. You say that this service is medically 
necessary. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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 pre-approve the 
prefabricated post and core (D2954).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower or bath chair. 
 
You asked the Plan to pre-approve a shower or bath chair. You say that this a shower/bath chair is medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor 
Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a 
shower or bath chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care rendered on November 24, 
2019. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 99226 is one. You billed two units of this code, exceeding the MUE. 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 subsequent observation care rendered on 
November 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gradient compression stocking/sleeves (A6549). 
 
You asked the Plan to pre-approve gradient compression stocking/sleeves. You say that the items are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stocking/sleeves are covered when 
specific criteria is met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of gradient compression stocking/sleeves have not been met. Therefore, we decided that the Plan does 
not have to pre-approve gradient compression stocking/sleeves (A6549).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastrointestinal transit and pressure measurement 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 the clinical documentation shows a colonoscopy that showed no bleeding and no acute 
findings. 
 
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 Wireless Motility Capsule (SmartPill, WMC) is FDA approved for evaluation of gastric emptying in 
gastroparesis, colonic transit in constipation and evaluation of generalized dysmotility. The device is 
recognized for assessment of gut dysmotilities by both the American Neurogastroenterology and Motility 
Society as well as by the American Gastroenterology Association. However, WMC has not been widely 
accepted as standard of care in clinical practice outside of tertiary care specialty centers and is not more readily 
available than gastric motility or colon transit testing. As such, while WMC is FDA-approved, more 
conventional motility studies that meet health plan coverage criteria should be considered. 
 
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 gastrointestinal transit and pressure measurement for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home International Normalized Ration (INR) testing 
supplies. 
 
You asked the Plan to pre-approve the requested supplies. You say that you have been out of supplies for 
months. The Plan denied your request. The Plan says the documentation does not show a current need for the 
requested supplies. 
 
The Plan follows Medicare rules. Medicare rules say that PT/INR monitoring is only covered under certain 
medical indications.  
 
The file shows that a twelve-month supply of INR testing was requested. The Plan has agreed to pre-approve a 
two-month supply. 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 requested 
supplies. Our physician reviewer found that the information sent in does not show recent notes from a doctor's 
office visit with exam, appropriate test results, or a current prescription. It is not known when you last were 
evaluated by your provider. The records do not show that continued INR testing is 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 the requested supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home International Normalized Ration (INR) testing supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and an ultrasound 
provided on August 26, 2020, and September 3, 2020. 
 
You asked the Plan to waive the copayments for a specialist visit and an ultrasound. You say that you disagree 
with the charges because you do not have access to telehealth. 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 $30 
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $30 
copayment for basic radiological services provided in a specialist's office. 
 
You had a specialist visit on August 26, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
You received an ultrasound on September 3, 2020. Therefore, you are responsible to pay the $30 copayment.  
 
The total amount you owe is: $60.   
 
You have been asked to pay the total copayment amount of $60 for a specialist visit and an ultrasound. A 
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. 
An ultrasound falls 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 copayments for a specialist visit and an ultrasound provided on August 26, 
2020, and September 3, 2020.