Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic shoes and inserts. 
 
You asked the Plan to pre-approve diabetic shoes and inserts. You say that diabetic shoes will reduce pressure 
and decrease swelling in your feet. 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 diabetic shoes and inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 
5, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that the 
orthoses were medically necessary. The Plan denied your request. The Plan says the enrollee did not receive a 
video or telephonic visit by the ordering physician in order to warrant the codes billed. 
 
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 the knee orthosis (L1833RT) and suspension 
sleeve (L2397RT). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer 
found knee instability must be documented by examination of the beneficiary and objective description of joint 
laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). The suspension sleeve is not a covered 
service if the knee orthosis is not covered. In this case, the enrollee has not had a recent injury or surgery. The 
documentation does not provide support for objective observation instability or laxity. The elements of the 
local coverage determination are not satisfied. 
 
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 knee orthosis (L1833RT) and suspension sleeve (L2397RT) have not been 
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve 
provided on October 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) 
provided from October 17, 2020, to October 27, 2020. 
 
You asked the Plan to pay for the continued stay at a SNF. You say that the services are coverable under the 
Medicare Act. The Plan denied your request. The Plan says the enrollee reached maximal gains possible. The 
Plan also says that the enrollee required no nursing services which would be considered skilled services by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the continued stay at a SNF. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the continued stay at a SNF have not been met. Therefore, we decided that the 
Plan does not have to pay for the continued stay at a skilled nursing facility (SNF) provided from October 17, 
2020, to October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the genetic testing provided on November 
11, 2020. 
 
You asked the Plan to waive the coinsurance for the genetic testing. You say that the genetic testing was not 
something you wanted completed. You say that they processed this test without your consent and you want to 
appeal the copayment. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for molecular or predisposition genetic testing. 
 
You have been asked to pay $774.60, which is 20% of the allowed amount for the genetic testing. The allowed 
amount is $3,873 (20% x $3,873 = $774.60). The genetic testing falls within the "Outpatient diagnostic tests 
and therapeutic services and supplies" benefit category. The records show the genetic testing was performed. 
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 the genetic testing provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), office visit for 
observation (D9430), first intraoral periapical x-ray (D0220), additional intraoral periapical x-rays (D0230), 
and bitewing x-rays (D0274) provided on October 26, 2020. 
 
You asked the Plan to pay for the oral hygiene instructions, office visit for observation, intraoral periapical x-
rays, and bitewing x-rays. You say that you believe these services should be covered. The Plan denied your 
request. The Plan says the oral hygiene instructions and office visit for observation are not covered benefits. 
The Plan also says that you had exceeded your benefit limit for intraoral periapical x-rays and bitewing x-rays. 
 
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 oral hygiene instructions and office 
visit for observation are not among those covered under this benefit. The Plan contract says that first intraoral 
periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and bitewing x-rays (D0274) are 
limited to 2 of either codes D0220, D0230, D0270, D0272, D0273, or D0274 per 1 calendar year. The record 
shows that you received three additional intraoral periapical x-rays (D0230 x3) provided on October 26, 2020, 
two of which were covered by the Plan, and your intraoral x-rays and bitewing x-rays benefits had been 
exhausted. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330), 
office visit for observation (D9430), first intraoral periapical x-ray (D0220), additional intraoral periapical x-
rays (D0230), and bitewing x-rays (D0274) provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on August 27, 
2020. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that the doctor is a specialist and 
there is no copayment for this under your plan. The Plan denied your request. The Plan says the copayment 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 
copayment for surgery services at an outpatient hospital. 
 
You have been asked to pay a $25 copayment for the arthrocentesis. The arthrocentesis falls within the 
"Outpatient hospital services" benefit category. The records show the arthrocentesis was billed by the hospital. 
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 arthrocentesis provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen.

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. Medicare rules say that oxygen is covered when specific criteria are met. 

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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you have an oxygen saturation of 90 percent on breathing room air. You have sleep apnea and use a continuous positive airway pressure (CPAP) device at night, but there is no submitted overnight oximetry data. The criteria for coverage are not met; therefore, the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the cost-sharing for telehealth services provided from April 21, 2020, to 
July 20, 2020. 
 
You asked the Plan to waive the cost-sharing for telehealth services. You say that these telemedicine calls 
should be covered. The Plan denied your request. The Plan says that the cost-sharing amounts you are being 
charged are correct. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for outpatient hospital telemedicine facility fees.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay 20% 
coinsurance for Outpatient Hospital Services. The Plan contract does not clearly say how much enrollees must 
pay for outpatient hospital telemedicine facility fees. This means that the Plan did not follow Medicare rules for 
disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the cost-sharing for 
telehealth services provided from April 21, 2020, to July 20, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 20, 
2020 to September 21, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record did not show that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier Emergency and/or 
observation care) would span two midnights. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided September 20, 2020 to September 21, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that the member would benefit from additional therapy 
sessions. The Plan denied your request. The Plan says that the enrollee may be equally well served at an 
alternative level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a stroke. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee.

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 Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to an error in the number of codes submitted for the panel. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day sensor. 
 
You asked the Plan to pre-approve a Freestyle Libre 14 day sensor. You say that this is medically necessary for 
you. The Plan denied your request. The Plan says that you do not meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre 14 day sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 14 day sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission. 
 
You asked the Plan to pre-approve inpatient admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient admission. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you were rushed to the hospital via ambulance with abdominal pain. You were not 
able to eat or drink for a day or so. You were treated with intravenous (IV) fluids, antiemetics, and analgesics. 
You condition stabilized and improved and you were discharged. The documentation does not support that you 
required or received inpatient level of care services. Therefore, you do not meet criteria for the requested 
inpatient 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 inpatient admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 17, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says you
must receive care from a network provider. In most cases, care received from an out-of-network provider will
not be covered with the exception of emergency care or urgently needed services, Medicare covered medical
care that the providers in our network cannot provide and dialysis services at a Medicare certified dialysis
facility when you are temporarily outside the plan's service area. A prior authorization is required if you are
seeking non-emergency out-of-network care.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nurse practitioner services provided on November 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 reviewer says that the 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for abdominal pain and shortness of 
breath. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair. 
 
You asked the Plan to pre-approve the group 3 power wheelchair. You say that you would like reconsideration 
because you qualify for this equipment. The Plan denied your request. The Plan says you currently have a 
power wheelchair which is less than 5 years old. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of the equipment is 
no less than 5 years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the group 3 power wheelchair have not been met. Specifically, the record indicates that you 
received a power wheelchair in 2019. Replacement due to wear is not covered during the reasonable useful 
lifetime of the equipment. Additionally, the record indicates that there has not been a change in condition 
which would qualify you for a replacement. Therefore, we decided that the Plan does not have to pre-approve a 
group 3 power wheelchair.