Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endoscopic lumbar decompression procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
procedure being planned as an endoscopic surgery is considered investigational at this time. 
 
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 requested procedure. Our physician 
reviewer found that the enrollee presents with left-sided low back pain radiating into the left lower extremity. 
Pain has worsened over the last 7 months. Functional limitations are noted in activities of daily living. There is 
imaging evidence of a left L5/S1 disc and spondylosis compressing the L5 nerve. He has reportedly failed to 
achieve sustained improvement with long-term conservative treatment. Current evidence based medical 
literature does not clearly support endoscopic transforaminal discectomy and foraminotomy over standard or 
microdiscectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use 
of these procedures for this enrollee. Additionally, clinical exam findings have not documented a focal 
neurologic deficit correlated with reported imaging evidence of left L5 nerve root compression. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request at this time. Therefore, this request 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 have not been met. Therefore, we decided that the Plan does not have to pre-
approve an endoscopic lumbar decompression procedure.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 bilateral knee 
osteoarthritis. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do 
not support that the required drugs would be contraindicated or less effective; therefore, Synvisc is not 
reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services. 
The Plan denied your request. The Plan says there are in-network providers available. 
 
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 
specialist services to be 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 a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this is medically necessary. The Plan denied 
your request. The Plan says the medical records do not support that the criteria for coverage have been met. 
 
The Plan follows Medicare rules. Medicare rules say that a semi-electric hospital bed is covered when medically 
necessary according to the above criteria. 
 
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 semi-electric hospital bed. Our reviewer says that the criteria 
for coverage have not been met. Our physician reviewer found the medical records do not support a need for an 
immediate or frequent change in body position. The physician note states that you need a hospital bed because you cannot 
get out of the bed by herself.  The request for a semi-electric hospital bed is not medically necessary 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 a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed (E0260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdomen x-ray rendered on July 6, 2020. 
 
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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct POS code. 
 
We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 22 for an 
outpatient hospital; however, the enrollee was under inpatient status for the date of service at issue. Therefore, 
we decided that the Plan does not have to pay for the abdomen x-ray rendered on July 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete urinary tract infection panel provided on 
January 30, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation 
submitted did not include a physician order or medical records stating exactly what tests are to be performed. 
 
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 the provided lab panel is not supported in the medical record. The documentation does not include 
the results of the testing at issue. There are insufficient records showing what specific tests are included in the 
test panel. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the complete urinary tract infection panel provided 
on January 30, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the complete mandibular denture. We decided that the Plan does not 
have to pay for precision attachment.  
 
You asked the Plan to pay for the complete mandibular denture. You say that you would like the Plan to 
reprocess this claim and approve for payment. The Plan says that you had this service last performed in 2018 
and the Plan only covers complete dentures every five years. 
 
We decided that the Plan has to pay for the complete mandibular denture.  
 
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. The Plan covers the complete 
mandibular denture once every five years. 
 
We looked at the file and Medicare rules. You received new dentures in 2018; however, you were not a 
member of the Plan at this time and they did not provide payment. Therefore, you have not exhausted your 
benefit for complete dentures, and the Plan is eligible to provide payment. Based on this information, we 
decided that the Plan's rules for coverage of the complete mandibular denture have been met. Therefore, we 
decided that the Plan has to pay for the complete mandibular denture.  
 
We also decided that the Plan does not have to pay for precision attachment. 
 
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 pay for precision 
attachment. 
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency treatment of dental pain (D9110) provided on 
July 9, 2020. 
 
You asked the Plan to pay for the emergency treatment of dental pain. You say that the services provided were 
medically necessary. The Plan denied your request. The Plan says these 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 pay for the 
emergency treatment of dental pain (D9110) provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on July 
17, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the 
charges because you feel that they should be part of the procedure. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on July 17, 2020. The allowed amount is $394.63 and 20% of that is 
$78.93.  
 
You have been asked to pay the total coinsurance amount $78.93 for a Medicare Part B drug. A Medicare Part 
B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on July 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
plan says that the referring facility is also out-of-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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for skilled nursing services provieded, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 8 and 9. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee currently has porcelain fused 
to metal crowns on teeth # 8 and 9. You say that the current crowns were placed over 40 years ago. You also 
say that the crowns are stable with discoloring along the gum line. The Plan denied your request. The Plan says 
services that are not considered reasonable and necessary 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 when they are not reasonable and necessary. Therefore, we decided that 
the Plan does not have to pre-approve porcelain crowns (D2740) for teeth # 8 and 9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on January 24, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy. You say that you have only ever paid a $50 
copayment in the past and disagree with the 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 20% 
coinsurance for chemotherapy drugs. You received chemotherapy on January 24, 2020. The allowed amount is $899.93 and 20% of that is $179.99.   
 
You have been asked to pay the total coinsurance amount of $179.99 for chemotherapy. Chemotherapy falls 
within the Medicare Part B prescription drugs 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 chemotherapy provided on January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the collection of blood specimen from a 
completely implantable venous access device provided on June 19, 2020. 
 
You asked the Plan to waive the copayment for the collection of blood specimen from a completely 
implantable venous access device. You say that you feel like this is a billing error. 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 $295 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
The collection of blood specimen from a completely implantable venous access device is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay $96, which is less than the $295 
copayment.  
 
You have been asked to pay $96 for the collection of blood specimen from a completely implantable venous 
access device. The collection of blood specimen from a completely implantable venous access device falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 
collection of blood specimen from a completely implantable venous access device provided on June 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the echocardiography provided
 
You asked the Plan to waive the copayment for the echocardiography (93971). You say that this service was 
part of the emergency room visit and should not have a copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 $45 
copayment for diagnostic tests from a specialty physician.  
 
You have been asked to pay a $45 copayment for the echocardiography (93971). The echocardiography 
(93971) falls within the diagnostic tests from a specialty physician 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 echocardiography provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis 
(74176) performed on July 15, 2020. 
 
You asked the Plan to waive the copayment for a CT scan of the abdomen and pelvis. You say that you 
received the same service in 2019 and paid a lower price. The Plan denied your request. The Plan says the 
correct copayment was 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 $155 
copayment for each Medicare-covered radiological diagnostic service, not including X-rays.  
 
You have been asked to pay a $155 copayment for a CT scan of the abdomen and pelvis. A CT scan of the 
abdomen and pelvis 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 a CT scan of the abdomen and 
pelvis (74176) performed on July 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an advanced pneumatic compression device (E0652) with leg 
appliances. 

You asked the Plan to pre-approve pneumatic compression device. You say that a basic compression pump has 
been ruled out, and this device is medically necessary. The Plan denied your request. The Plan says that the 
denial of authorization for this device is correct, because the records show that the enrollee has chronic venous 
insufficiency without leg ulcers. 
 
The Plan follows Medicare rules. Medicare rules say that an advanced pneumatic compression device is only 
covered under certain indications after a basic compression device has failed a four-week trial. 
 
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 pneumatic compression device. Our 
reviewer says that the enrollee meets the Medicare criteria for the requested pneumatic compression device. 
Our physician reviewer found the enrollee has refractory edema with no therapy that is effective. He has failed 
a reasonable trial of a basic pump. The enrollee is at risk for complications with persistent lymphedema. 
Having failed standard therapy, this device is indicated and medically 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 pneumatic compression device have been met. Therefore, we decided that the 
Plan has to pre-approve an advanced pneumatic compression device (E0652) with leg appliances.  
 
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: Favorable

 
We decided that the Plan has to pre-approve a Pneumatic Compression Device (E0667, E0652). 
 
You asked the Plan to pre-approve the Pneumatic Compression Device. You say that the device is medically 
necessary. The Plan denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Pneumatic Compression Device is covered when 
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 Pneumatic Compression Device.. 
Our reviewer says that the requested Pneumatic Compression Device is medically necessary. Our physician 
reviewer found the enrollee has refractory lymphedema that has failed basic compression and conservative 
therapy. The record shows worsening changes resulting from the chronic edema. 
 
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 Pneumatic Compression Device. have been met. Therefore, we decided that 
the Plan has to pre-approve a Pneumatic Compression Device (E0667, E0652).  
 
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.