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

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on 
July 14, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The 
Plan denied your request. The Plan says the copayment was 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 $20 
copayment for all other Medicare-covered outpatient hospital services.  
 
Review of the file shows that you received outpatient hospital services on July 14, 2020. You have been asked 
to pay a $20 copayment for these services. These services fall within the all other Medicare-covered outpatient 
hospital services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient 
hospital services rendered on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vascepa, 1 gm capsule, 2 capsules twice per day. 
 
You asked the Plan to pre-approve Vascepa. You say that the enrollee has been on Vascepa for 8 months. You 
say that lab tests shows that the enrollee is responding to the medication with a reduction in her Triglyceride 
level. You say that an exception should be made so that the enrollee can continue treatment. The Plan denied 
your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa, 1 gm capsule, 2 
capsules twice per day.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that your records show you do not have a complex illness 
requiring further hospital care, you do not need daily doctor visits, or special nursing care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. You are receiving 
acute hospital care, and acute care services have not been denied. The documentation does not support that you 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. Our physician reviewer found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided June 1, 
2020 to June 10, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should 
be waived. 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 $325 
per day copayment for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $1,625 copayment for the first 5 days of the inpatient admission ($325 per day). 
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 inpatient hospital care provided June 1, 2020 to June 10, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology service provided on June 17, 2020. 
 
You asked the Plan to pay for the radiology service (71045). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says thoracentesis (32555) was performed by the same provider and 
therefore the radiology service cannot be paid separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 32555 
has a bundled relationship with code 71045 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for the radiology service provided on June 17, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve multiple sleep latency testing (MSLT) for the enrollee. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say services are covered if they are 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 testing. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found coverage criteria for polysomnography with MSLT are met. The enrollee has excessive daytime 
sleepiness, falling asleep inappropriately during the day, and symptoms suggestive of cataplexy.  The reason 
for the sleep test is suspicion of narcolepsy, as documented in the medical records.  The MSLT is the 
appropriate test for this.  Polysomnography with MSLT is considered 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 the testing have been met. Therefore, we decided that the Plan has to pre-
approve multiple sleep latency testing (MSLT) for the enrollee.  
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided to the enrollee on 
August 27, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered point of origin.  
 
The services you have asked the Plan to pay for are ambulance transport services from a doctor's office to the 
enrollee's residence. Therefore, we decided that the Plan does not have to pay for the ambulance transportation 
provided to the enrollee on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that your receiving injections for heal pain. 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 foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca (Q5111), 6mg. 
 
You asked the Plan to pre-approve Udenyca. You say that the enrollee has growth factors. You also say that the 
enrollee is neutropenia with an A1C of 200 while on chemotherapy. The Plan denied your request. The Plan 
says the use of this drug in your case requires using a chemotherapy regimen that has an intermediate (10-20%) 
or high (>20%) risk of causing febrile neutropenia. The Plan also says that the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Udenyca. Our reviewer says that the 
requested drug does not meet the criteria for coverage. Our physician reviewer found the requested use is not 
FDA approved. The reviewer found that the requested use is not supported in any of the CMS approved 
compendia. Therefore, the reviewer found that there is insufficient information to determine that Udenyca 
would impact the planned dose. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Udenyca (Q5111), 6mg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calcipotriene 0.005% cream. 
 
You asked the Plan to pre-approve Calcipotriene cream. You say that the enrollee has been prescribed 
Calcipotriene in conjunction with Efudex 5% for a recently proven treatment for Actinic Keratoses. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Calcipotriene 0.005% 
cream.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure, adjunctive procedure, and additional intraoral periapical x-ray provided on June 8, 2020.You asked the Plan to pay forthe preventive procedure, adjunctive procedure, and additional intraoral periapical x-ray. You say that your teeth and gums are in terrible shape as a result of thecontinual acid problem. You also say that you feel that these services were rendered due to a medical condition, and not a dental condition.The Plan denied your request. The Plan says these 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, unspecified preventive procedure and unspecified adjunctive procedure are not among those covered under this benefit. The Plan contract clearly states that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 8, 2020, and your intraoral x-rays benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe preventive procedure, adjunctive procedure, and additional intraoral periapical x-ray provided on June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are in dire need of these. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultraviolet light therapy system (E0691). 
 
You asked the Plan to pre-approve an ultraviolet light therapy system. You say that although the enrollee's 
psooriasis responds to topical medication, it is not controlled. The Plan denied your request. The Plan says the 
criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PUVA therapy is covered for treatment of 
intractable, disabling psoriasis, but only after the psoriasis has not responded to more conventional treatment. 
 
We looked at the file and Medicare rules. The records show that the enrollee's psoriasis responds to 
conventional therapy. Based on this information, we decided that Medicare rules for coverage of an ultraviolet 
light therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
ultraviolet light therapy system (E0691).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on 
November 26, 2019. 
 
You asked the Plan to pay for physical therapy. You say that you provided claims along with daily notes for the 
correct dates of service. The Plan denied your request. The Plan says in-network providers were 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 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 physical therapy provided by an out-of-network 
provider on November 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids received on July 7, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you go to a multi-specialty facility for your 
medical care. The Plan denied your request. The Plan says hearing aids are only covered from network 
providers. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when provided by the network provider for hearing aids. 
 
The hearing aids were not purchased from the plan's preferred hearing aids provider. Based on this information, 
we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that 
the Plan does not have to pay for hearing aids received on July 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 88305, CPT 88311) provided on April 1, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We asked our coding 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 services Our reviewer says that the 
records support the number of units billed for CPT 88305. Our coding reviewer found that the medical records 
provided do not include sufficient information to support billing 2 units of 88305 for services rendered on April 
1, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CPT 88305 have not been met. 
 
 
 
The rules also say that add-on codes can only be reported in addition to a primary procedure. When the CPT 
Manual identifies specific primary codes, the add-on code shall not be reported as a supplemental service for 
other HCPCS/CPT codes not listed as a primary code. We find that payment for CPT code 88311 is not 
supported. Specifically, CPT code 88311 is an add-on code, and is not payable because the primary procedure 
code is not supported. Therefore, we decided that the Plan does not have to pay for the services (CPT 88305, 
CPT 88311) provided on April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the caries risk assessment and documentation (D0601) and 
problem focused limited oral evaluation (D0140) provided. 
 
You asked the Plan to pay for the caries risk assessment and documentation and problem focused limited oral 
evaluation. You say that these services were provided on an emergency basis. You also say that you are not 
sure if the dentist provided a caries risk assessment and documentation or not. The Plan denied your request. 
The Plan says the caries risk assessment and documentation is not a covered benefit. The Plan also says that the 
maximum allowed for oral exams had been met. 
 
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, caries risk assessment and 
documentation is not among those covered under this benefit. The Plan contract also says that oral exams are 
limited to 1 every 6 months. The record shows that you received a comprehensive oral evaluation, and your oral 
exams benefit had been exhausted. Therefore, we decided that the Plan does not have to 
pay for the caries risk assessment and documentation (D0601) and problem focused limited oral evaluation 
(D0140) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture with resin base (D5211) and a 
lower partial denture with resin base (D5212). 
 
You asked the Plan to pre-approve the dental items. The Plan denied your request. The Plan says dentures are 
covered once per 60 months. The Plan says that the frequency limit for dentures has been reached. 
 
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 frequency limit for dentures of 
once per 60 months has been reached. The record shows that the Plan paid for partial dentures that you 
received on March 6, 2018. Additionally, the Customer Handbook specifically says any services provided that 
are over the frequency limit are not covered. Therefore, we decided that the Plan does not have to pre-approve 
an upper partial denture with resin base (D5211) and a lower partial denture with resin base (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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, especially over a prosthesis. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator for the 
enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the doctor does not support that this is being done as a last resort. 
 
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 stimulator. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrolle has not had a surgical evaluation and has not has trials of multiple pain drug classes. 
Therefore, the enrollee does not meet the criteria of the NCD. The request is not medically reasonable or 
necessary at this point. 
 
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 stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of a neurostimulator for the enrollee.