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

 
We decided that the Plan does not have to pre-approve a replacement of a prosthetic leg with an advanced foot 
feature. 
 
You asked the Plan to pre-approve a replacement of a prosthetic leg with an advanced foot feature. You say 
that the items are necessary. The Plan denied your request. The Plan says based on the documentation 
provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that claims involving the replacement of a prosthesis or 
major component (foot, ankle, knee, socket etc.) must be supported by a new treating practitioner's order and 
documentation supporting the reason for the replacement.  
 
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 replacement of a prosthetic leg with 
an advanced foot feature. Our reviewer says that the items are not medically necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that a replacement of the prosthetic leg 
with an advanced foot feature is medically necessary in this case. There is no description of damage to the 
present prosthetic foot necessitating the replacement requested. A replacement socket that meets your needs 
does appear indicated. 
 
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 replacement of a prosthetic leg with an advanced foot feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a replacement of a prosthetic leg with an 
advanced foot feature.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete maxillary dentures (D5110) and complete 
mandibular dentures (D5120). 
 
You asked the Plan to pre-approve complete maxillary dentures (D5110) and complete mandibular dentures 
(D5120). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The 
Plan says the complete dentures you are requesting are covered only once every five years. The Plan says that 
you received complete upper and lower dentures on July 8, 2019, which is less than five years ago. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete dentures 
(D5110 and D5120) are only covered once every five years. The file shows that you received complete 
dentures on July 8, 2019, which is less than five years ago. The Plan says that they called your provider and 
they are able to work with you to fix your dentures. Therefore, we decided that the Plan does not have to pre-
approve complete maxillary dentures (D5110) and complete mandibular dentures (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is felt that LTACH would best meet 
the enrollee's needs. The Plan denied your request. The Plan says an LTACH is not able to provide any superior 
services to those available in the current facility. The enrollee can remain in the current facility until hospital 
care is no longer required. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found The enrollee has a history of diabetes, hypertension, and obstructive sleep apnea. She 
presented to the acute care hospital on 8/12/20 unresponsive. She was diagnosed with COVID-19 pneumonia. 
The enrollee required intubation to protect her airway. She is now on a trach collar. On 9/14/20, the enrollee 
was nonverbal and did not follow commands. She has persistent multifactorial encephalopathy. The enrollee 
has a stage 2 sacral pressure ulcer. 
 
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 member 
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 she is currently receiving care. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of 
SNF care from September 8, 2020 and forward is medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for continued SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 pre-approve the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not 
require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional 
nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The 
enrollee does not have complex wound care or other ongoing SNF level skilled nursing need. The enrollee's 
functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of 
a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. 
The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on 
a daily basis in a SNF. As a practical matter, this enrollee does not require the necessary services on an 
inpatient basis, in a skilled nursing facility 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 continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat elevation system and functional reach package for 
the enrollee's power wheelchair. 
 
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the items 
do not serve a primary medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature, and is non-covered. 
Therefore, we decided that the Plan does not have to pre-approve a seat elevation system and functional reach 
package for the enrollee's power wheelchair.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you receive dialysis treatments three 
days per week. The Plan denied your request. The Plan says your benefit only allows 60 trips for this service. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Once you have used 60 one-way trips, you 
will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $50 copayment for specialist services provided on May 
11, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the 
provider and the Plan contract agreement. 
 
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 
copayment for specialist services.  
 
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 $50 copayment for specialist services provided on May 11, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment charged for emergency room services 
provided on December 23, 2019. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $90 
copayment for emergency room services.  
 
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 $90 copayment charged for emergency room services provided on December 23, 
2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve home health services. You say that you are having trouble walking long 
distances. The Plan denied your request. The Plan says there is no documentation that you are confined to your 
home. 
 
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care 
services to be covered.  
 
The file does not show that you are homebound. Therefore, we decided that the Plan does not have to pre-
approve home health physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan has to pre-approve an UltraVoice speaking device. 
 
You asked the Plan to pre-approve the UltraVoice device. You say that it is felt that this device would work for 
the enrollee and should be covered. The Plan denied your request. The Plan says that this device requires a 
larynx to be effective and this enrollee has had a total laryngectomy. 
 
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 UltraVoice device. Our reviewer 
says that the requested device is considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of laryngectomy and prior failure of a different type of speech device. 
This was denied by the Plan stating that it cannot be used on those without a larynx.  
 
The records show that the ordering provider who is familiar with patient's anatomy and the device feels it will 
work properly. The enrollee has failed a trial of a different type of device. There was a clarification of the 
purpose of the device from the manufacturer to support that it is proper for this type of patient. The use of this 
device is medically reasonable and necessary in this situation. 
 
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 UltraVoice device have been met. Therefore, we decided that the Plan has to 
pre-approve an UltraVoice speaking device.  
 
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 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 
for the enrollee. The Plan denied your request. The Plan says that the member's current needs are being met in 
the acute setting. 
 
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. The patient 
appears to be improving and likely to be able to transfer to a lower level of care in less than 25 days. The 
patient does not require any services at the LTACH that are not already available at the current facility. 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe 
gingival inflammation (D4346) provided on February 27, 2020. 
 
You asked the Plan to pay for the scaling. You say that you opted to purchase dental coverage, which includes 
cleanings. You also say that this service should be covered by the Plan because you were told that your teeth 
needed to be cleaned by a dental professional. The Plan denied your request. The Plan says this service is not a 
covered benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
scaling in presence of generalized moderate or severe gingival inflammation (D4346) provided on February 27, 
2020.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Cxbladder testing provided on May 12, 2020. 
 
You asked the Plan to pay for genetic testing. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says that the denial of payment for this testing is correct, because this test is not 
covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this 
testing would not be covered. This testing is not explicitly excluded from Medicare coverage. Without this 
information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the 
Plan has not shown that its decision to deny payment for this testing is correct or justified according to 
Medicare rules. Therefore, we decided that the Plan has to pay for Cxbladder testing provided on May 12, 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 11, 
2020. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you had not had a colonoscopy for 
15 years and nothing was found during this surgery, therefore it should be preventive. The Plan denied your 
request. The Plan says the copayment amount you are being charged is 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 clearly says that you must pay $400 
copayment for diagnostic colonoscopy at an outpatient hospital. The record shows that this colonoscopy was 
provided due to the non-routine indication of positive results of a prior Cologuard test, therefore this is 
considered to be a diagnostic colonoscopy and not a preventive or screening service. 
 
You have been asked to pay $400 copayment for colonoscopy. Colonoscopy falls within the Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgery 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 a colonoscopy provided on March 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 9, 2019. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover 
this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic 
testing provided on April 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays provided on 
January 9, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you only went for your 
free yearly exam and cleaning. You also say that you were not asked to do the x-rays, but they were done 
because you had not seen a dentist in five years. The Plan denied your request. The Plan says benefits for this 
service have been satisfied and the frequency limitation has been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and two 
additional intraoral periapical x-rays on January 9, 2020, the Plan covered the first intraoral periapical x-ray, 
and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay 
for the two additional intraoral periapical x-rays provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for CPT code 71045 provided on September 4, 2019. 
 
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says that the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the denial of payment is based on the enrollee being a participant in 
a clinical research program. The Plan failed to provide any documentation showing that the enrollee is involved 
in a clinical research program and we find that the Plan has not substantiated their reasoning for denial. 
Therefore, we decided that the Plan has to pay for CPT code 71045 provided on September 4, 2019.  
 
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.