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

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have waited six years for this provider. The 
Plan denied your request. The Plan says the service is available within the network. 
 
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 only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two office visits to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plna to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
two office visits to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22869). 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869). You say that you believe this procedure to be the proper and safer treatment alternative than 
current treatment options. The Plan denied your request. The Plan says the Superion interspinous spacer 
procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains 
experimental for use in spinal surgery. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve Insertion of 
Interlaminar/Interspinous Process Stabilization/Distraction Device (22869).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 24, 2020, to 
March 26, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care provided was 
medically necessary. The Plan denied your request. The Plan says that inpatient care was not medically 
necessary, and the treatment could have been performed at a lower level, such as observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found this was an elderly patient who presented to the hospital with febrile illness. There was a high 
enough suspicion for serious medical complications that it was medically reasonable, given age and the 
presence of an unknown febrile illness, to make hospitalization 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from March 24, 2020, to March 26, 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 provide an automatic blood pressure monitor. 
 
You asked the Plan to provide an automatic blood pressure monitor. You say that you need to monitor your 
blood pressure. The Plan denied your request. The Plan says home blood pressure monitors are only covered 
for enrollees on home dialysis. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to provide an automatic blood pressure monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on June 26, 2020, to July 14, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $35 copayment for specialist services. The total amount you are being asked to 
pay is $210 ($35 x 6 visits = $210). The correct copayment has been applied to each visit that was provided. 
Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on 
June 26, 2020, to July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new prosthetic leg. 
 
You asked the Plan to pre-approve prosthetic leg. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the denial of authorization for these prostheses is correct, because 
while the records show that a new socket is needed, they do not show why a replacement foot is needed. 
 
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 prosthetic leg. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this request appears to exceed the enrollee's functional need as there is no documentation from 
the treating provider that the enrollee is a K3 ambulator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of prosthetic leg have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a new prosthetic leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for  hospital care provided on May 23, 2020, 
through May 26, 2020. 
 
You asked the Plan to waive the deductible for inpatient hospital care that was provided. You say that the 
amount charged on your bill is wrong.  The Plan denied your request. The Plan says that you have a $750 
deductible. This is the amount you must pay out-of-pocket before the Plan will pay for your covered medical 
services. 
 
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 $750 deductible that the members must pay out-of-pocket before the 
plan will pay their share of the covered medical services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 out-of-pocket 
deductible before the Plan will pay their share of the covered medical services. This cost sharing is a 
contractual obligation that had not been met at the time the inpatient medical care services were received on 
May 23, 2020, through May 26, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for  hospital care provided on May 23, 2020, through May 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interim partial denture (D5820), pontics (D6245) 
and retainer crown (D6740). 
 
You asked the Plan to pre-approve the interim partial denture (D8520), pontic (D6245) and retainer crown 
(D6740). The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 
interim partial denture (D5820), pontics (D6245) and retainer crown (D6740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve the requested services. You say that therapeutic injections are needed to 
relieve pain. The Plan denied your request. The Plan says the enrollee received no relief from diagnostic 
injections. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered under certain 
medical indications.  
 
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 services. Our physician 
reviewer found that the enrollee has a history of chronic low back pain and cervical facet syndrome. Per the 
documentation, the enrollee received no relief from diagnostic facet injections. Subsequently, a spinal cord 
stimulator was placed for pain relief. Subsequently, a spinal cord stimulator was placed for pain relief. The 
review has determined that the requested therapeutic facet joint injections are not indicated or necessary for the 
enrollee's condition. 
 
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 services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided 
from July 4, 2020 to July 5, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency room services on the dates of service at issue in 
this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $100 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency care 
services from July 4, 2020 to July 5, 2020. The file does not show that you were admitted as inpatient. You 
have been asked to pay a $100 copayment for the emergency room services. The emergency room services fall 
within the Emergency care 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 
emergency room services provided from July 4, 2020 to July 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D6740). 
 
You asked the Plan to pre-approve the services. You say that you are unable to eat with your temporary bridge. 
The Plan denied your request. The Plan says this is 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 
dental services (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a root canal (endodontic therapy) and core buildup for 
tooth 20. 
 
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 covered. 
 
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 a 
root canal (endodontic therapy) and core buildup for tooth 20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulators (TENS) 
(E0730, E0720). 
 
You asked the Plan to pre-approve TENS unit. You say that this portable and home therapy is crucial in 
reducing the enrollee's chronic and sometimes debilitating pain from 5 cervical fusions and lumbar issues. The 
Plan denied your request. The Plan says the criteria for medical necessity has not been documented as being 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Medicare does not cover transcutaneous electrical nerve stimulators 
for the treatment of chronic low back pain without being enrolled in an approved clinical study. There is no 
documentation of the member being enrolled in such study. Based on this information, we decided that 
Medicare rules for coverage of TENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcutaneous electrical nerve stimulators (TENS) (E0730, E0720).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to 
obtain the proper authorization. The Plan denied your request. The Plan says the services were not urgent, 
emergent, or approved in advance. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional drainage bags. 
 
You asked the Plan to pre-approve additional 6 per 90 days of Bedside drainage bag, day or night, with or 
without anti-reflux device, with or without tube, each (A4357), and additional 15 per 90 days of Urinary 
drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each (A4358). You say that you need a 
greater quantity of drainage bags because you are susceptible to UT infections. The Plan denied your request. 
The Plan says the documentation does not support medical necessity for a greater quantity of supplies than the 
amounts specified. 
 
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 additional 6 per 90 days of Bedside 
drainage bag, day or night, with or without anti-reflux device, with or without tube, each (A4357), and 
additional 15 per 90 days of Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, 
each (A4358). Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records do not provide rationale for additional 
urinary drainage bags. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional 6 per 90 days of Bedside drainage bag, day or night, with or without 
anti-reflux device, with or without tube, each (A4357), and additional 15 per 90 days of Urinary drainage bag, 
leg or abdomen, vinyl, with or without tube, with straps, each (A4358) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional drainage bags.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary due to the enrollee's visual impairment. The Plan denied your request. The Plan 
says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors are covered for 
enrollees who are insulin-treated with multiple daily injections of insulin.  
 
We looked at the file and Medicare rules. The record shows the enrollee is not treated with insulin injections. 
Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(K0554).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that this is not 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 
buildups for the enrollee.