Persius/hicric huggingface dataset:
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 monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not reflect current insulin treatment. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you are noted to be a diabetic. In November 2020, this was poorly controlled, and you were incorrectly 
taking your medications. At that time, your medications were adjusted/corrected to include two oral 
medications and once daily combination insulin. There is no documentation to how you have responded to 
these changes. There is no documentation to how often you care checking your blood glucose levels (i.e. BG 
log). There is no evidence that you use the results of blood glucose testing to self adjust your insulin dose 
multiple times per day. As such, the requested monitor is not shown to be medically necessary or reasonable. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs intense therapy and to be 
monitored by a physician due to acute decline. The Plan denied your request. The Plan says the enrollee's care 
is not complex, and does not need a team of providers. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital for COVID-19 pneumonia. Her medical conditions are 
stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on June 17, 2020. 
 
You asked the Plan to pay for the emergency room services. You say that the Plan is legally required to pay for 
these services. The Plan denied your request. The Plan says Medicare payment can only be made to Indian 
Health Service facilities when the proper billing rules are followed. 
 
The Plan must follow Medicare rules. Medicare rules say that IHS facilities must billed using revenue code 
0510 for outpatient services billed to Medicare.  
 
In this case, the correct revenue code was not used for IHS Medicare billing. Therefore, we decided that the 
Plan does not have to pay for the emergency room services provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on August 5, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you should not be responsible for this
copayment because you were referred for this service by your provider. The Plan denied your request. The Plan
says you have been charged the correct cost sharing 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 $250
copayment for Medicare-covered diagnostic radiology services (not including x-rays).
You have been asked to pay a $250 copayment for the MRI. The MRI 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 copayment
for the MRI provided on August 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage in moving the member from the current acute care hospital to an LTACH.

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. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe breast biopsy provided on September 16, 2020.You asked the Plan to reduce the copayment forthe breast biopsy. You say that you were told that the biopsy was completely covered. You say you should only have a $35 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment for each in-network Medicare-covered outpatient hospital facility. You have been asked to pay a $250 copayment for the breast biopsy. The breast biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that the breast biopsy is considered a surgical procedure.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 inthe Plan. Therefore, we decided that the Plan does not have to reduce the copayment forthe breast biopsy provided on September 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided 
on July 29, 2020. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree 
with the facility fee charges. 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 $350 
copayment for each Medicare-covered non-surgical visit in an outpatient clinic for outpatient hospital services.  
 
You have been asked to pay $132.80, which is less than the $350 copayment for an outpatient hospital facility 
visit. An outpatient hospital facility visit falls within the outpatient hospital 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 an outpatient hospital facility visit provided on July 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custodial care services from July 20, 2020, to August 25, 
2020. 
 
You asked the Plan to pay for custodial care services. You say that you were not able to enter rehabilitation and 
needed assistance. The Plan denied your request. The Plan says these services are not covered by your benefit. 
 
The Plan must follow Medicare rules. The rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of custodial care services have not been met. Therefore, we decided that the Plan does not have to pay 
for custodial care services from July 20, 2020, to August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) for the 
lower left quadrant. 
 
You asked the Plan to pre-approve the dental service. You say that you have diabetes. You say that you need 
this service because your gums will not heal. The Plan denied your request. The Plan says periodontal scaling 
and root planing 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 the 
periodontal scaling and root planing (D4341) for the lower left quadrant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to backdate a prior authorization and/or pay 5 months rental for a semi-
electric hospital bed provided to the enrollee staring on July 15, 2019. 
 
You asked the Plan to pay for 5 months of semi-electric hospital bed rental provided to the enrollee starting on 
July 15, 2019. You say that Medicare allows 13 months of payments and that the Plan has only paid 8 months. 
You say that the enrollee has had this equipment since July 2019, and you should receive the full 13 months of 
payments since you are still servicing the enrollee.  
 
The Plan states the Plan contract shows DME requires prior authorization. As a plan provider, you should have 
requested prior authorization prior to delivering this equipment. The Plan denied your request to back date the 
prior authorization. The Plan approved prior authorization for 8 months. The Plan notes that the enrollee has 
paid for 13 months rental and cannot be expected to make further payments. The Plan further notes the enrollee 
cannot be held responsible for the error a provider made when it delayed the request for the initial prior 
authorization a year after delivering the equipment.    
 
Medicare rules say that Plans can require enrollees to get prior authorization. The contract with the Plan says 
that DME requires prior authorization. The prior authorization form shows you did not request authorization 
for this equipment until October 22, 2020 and it was marked as continued. There is no record showing you 
requested prior authorization before you delivered this equipment to the enrollee in July of 2019. It should also 
be noted that the physician order provided for review with your appeal shows it was signed on November 9, 
2019. There is no explanation in your appeal as to why over a year passed before prior authorization was 
requested. As a Plan contract provider, you have an agreement with the Plan that you will follow all of the Plan 
rules for providing durable medical equipment and services to the enrollee and will accept those payments 
issued by the Plan. The Plan is correct, the enrollee cannot be held responsible for a provider?s error in 
obtaining prior authorization and assuring their claims are paid correctly. The Plan reports the enrollee has 
made 13 payments.  
 
As a Plan provider, you do not have appeal rights with the IRE for payment. You presented this as a pre-service 
appeal, for 13 months of payment. The Plan paid 8 months; however, the Plan is not required to backdate a 
prior authorization or make future payments for a service that has already occurred and for a service the 
enrollee has already paid for. Therefore, we decided that the Plan does not have to pay 5 months rental for a 
semi-electric hospital bed provided to the enrollee staring on April 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
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 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 not medically necessary. Our physician reviewer found the enrollee has metastatic colon 
cancer. Keytruda is not FDA-approved for use in colorectal cancer or supported by the major drug compendia 
or medical literature. Keytruda is approved for patients with high microsatellite instability (MSI-H)/deficient 
mismatch repair (dMMR) tumors, but the enrollee does not have this. The Keytruda is not reasonable or 
medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle orthosis provided on June 29, 2020. 
 
You asked the Plan to pay for the ankle orthosis. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the item rendered is 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. 
 
In this case, the CPT Code Manual definition of code L1902 is ankle orthosis, ankle gauntlet or similar, with or 
without joints, prefabricated, off-the-shelf. 
 
We find that CPT code L1902 is not supported in the medical record. Specifically, the enrollee had previously 
received the same item from a different provider on May 22, 2019. This is prior to the five years which 
Medicare determines is the reasonable useful lifetime for the equipment. The records submitted did not include 
documentation to support that the replacement of this brace was necessary due to loss or irreparable damage. 
This is prior to the five years which Medicare determines is the reasonable useful lifetime for the Based on this 
information, we decided that Medicare rules for coverage of the ankle orthosis have not been met. Therefore, 
we decided that the Plan does not have to pay for the ankle orthosis provided on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested items are not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 a power wheelchair and accessories. 
Our reviewer says that the requested power wheelchair is not medically reasonable or necessary. Our physician 
reviewer found the documentation does not reveal that you have a personal mobility deficit that impairs 
participation in mobility related activities of daily living in the home. The treating medical practitioner progress 
note and your appeal indicate that you get shortness of breath when walking. This is inconsistent with the 
occupational therapy evaluation that your bilateral lower extremity strength is 2+ out of 5 which is 
incompatible with ambulation. A 2+ out of 5 grade is assigned when a muscle can contract but cannot move the 
body against gravity. Given the inconsistencies with strength and function and no detailed upper and lower 
neuromuscular or gait evaluation on the treating medical practitioner progress note that may support whether or 
not you are able to use a manual wheelchair or walker safely and effectively the request for a power wheelchair 
and accessories is not medically 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 a power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2), bone 
replacement graft for a retained natural tooth (D4263), bone replacement graft (D7953), and the surgical 
placement of an endosteal implant (D6010 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you have a chronic condition in the blood. 
You say that due to your condition, you have weakened the enamel of your teeth. You say that you have many 
dental complications. You also say that these services are not for aesthetics but for medical necessity. The Plan 
denied your request. The Plan says the requested services are dental in nature. The Plan also says that the 
requested services are not listed as covered services. 
 
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. Additionally, the services you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pre-approve guided tissue regeneration (D4266 x 2), bone replacement graft for a 
retained natural tooth (D4263), bone replacement graft (D7953), and the surgical placement of an endosteal 
implant (D6010 x 2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit provided on August 4, 
2020. 
 
You asked the Plan to waive the coinsurance for an office visit. You say that you thought that you would only 
owe a $20 copayment. 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 50% 
coinsurance for out-of-network physician/practitioner services, including doctor?s office visits.  
 
You had an office visit with an out-of-network provider on August 4, 2020. Therefore, you are responsible to 
pay your share of the out-of-network charges. The total allowed amount is $113.03 and 50% of that is $56.52.  
 
You have been asked to pay the total coinsurance amount of $56.52 for an office visit. An office visit 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. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an office visit provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additional reimbursement for eyewear purchased on August 12, 
2020. 
 
You asked the Plan to pay additional reimbursement additional reimbursement. You say that the Plan should 
pay more of the cost of this eyewear. The Plan denied your request. The Plan says the claim submitted for this 
eyewear by the provider was $504. The Plan paid $150 vision benefit toward this claim. This leaves a balance 
of $354, which you would have been responsible for. The Plan states you are not responsible for any other cost 
and you are not being billed for any additional cost. 
 
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 there is a $150 vision 
benefit for eyewear. This benefit was applied to the amount billed of $504 leaving a financial responsibility of 
$354. The Plan has applied the allowed benefit and is not required to provide additional reimbursement.  
Therefore, we decided that the Plan does not have to pay additional reimbursement for eyewear purchased on 
August 12, 2020.