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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the requested services. You say that you have low oxygen levels. The Plan 
denied your request. The Plan says your oxygen saturation level is not at or below 88%. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that coverage criteria for home oxygen are not met. You have a diagnosis of bronchiectasis.  
The medical records document an oxygen saturation of 93%, which does not establish a need for supplemental 
oxygen.  There are no other oxygenation data.  Therefore, the requested oxygen 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 of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on July 22, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have large tori bone growth making 
traditional x-rays painful and ineffective. You say that the x-rays should therefore be covered. The Plan denied 
your request. The Plan says bitewing x-rays are not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
bitewing x-rays (D0274) provided on July 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93880) and echocardiography (93306) 
provided on March 9, 2020. 
 
You asked the Plan to pay for the duplex scan and echocardiography. You say that you should not be 
responsible for the amount charged. The Plan denied your request. The Plan says based on Medicare criteria, 
the claims were billed 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 until you have met the 
$1,000 deductible, you must pay the full cost of the covered services.  
 
You have been asked to pay $454.67 (the allowed amount) for the duplex scan and echocardiography. You 
have not met the $1,000 deductible. 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 pay for the duplex scan (93880) and 
echocardiography (93306) provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (99214) provided November 7, 2019 to 
December 31, 2019. 
 
You asked the Plan to pay for the physician services. You say that the claim should be paid. The Plan denied 
your request. The Plan says payment has already been issued for evaluation and management services provided 
by this physician on the dates of service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 99214 is not supported in the record. Specifically, the documentation provided by the 
plan shows payment for an evaluation and management (physician) service by this provider under claim 
number 820202331209864. Medicare allows payment to a physician for one Evaluation and Management code 
per date of service. Based on this information, we decided that Medicare rules for coverage of the physician 
services have not been met. Therefore, we decided that the Plan does not have to pay for physician services 
(99214) provided November 7, 2019 to December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial 
of drug Zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug. Our reviewer found that there is no documentation provided indicating that the Plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician 
reviewer also found that the enrollee does not have a history of osteoporosis-related fracture. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the office visit or pay for the assessment 
provided on July 28, 2020. 
 
You asked the Plan to adjust the copayment and pay for the office visit and the assessment. You say that the 
copayment is wrong and the assessment should be covered. The Plan denied your request. The Plan says you 
were charged this copayment correctly and the assessment is not covered since you had on already this year. 
 
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 $50 
copayment for physician specialist services.  
 
You received your yearly depression screening on January 27, 2020. Only one is covered per year. You have 
been asked to pay a $50 copayment for the office visit. The office visit falls within the physician specialist 
services benefit category and was billed as endocrinology specialty. 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 adjust the 
copayment for the office visit or pay for the assessment provided on July 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from May 12, 2020, to 
June 10, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled 
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that the enrollee received 100 days of SNF care during the benefit period from November 8, 
2019, to February 23, 2020. The Plan has covered 100 days of SNF care.  
 
 
 
 
 
 
 
 
 
 
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has 
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided 
that the Plan does not have to pay for the skilled nursing services provided from May 12, 2020, to June 10, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-one (J7325). 
 
You asked the Plan to pre-approve Synvisc-one. The Plan denied your request. The Plan says the information 
submitted does not meet the Plan's medical necessity guidelines for coverage. 
 
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 Synvisc-one. Our reviewer says that 
Synvisc-one is not medically reasonable and necessary for the enrollee. Our physician reviewer found the 
enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as 
outlined by the Plan, requires these be trialed first. Our reviewer found that the documentation does not outline 
contraindications or reasons these medications were not considered. Our physician reviewer also found that 
without the support of the documentation, Synvisc-One is not approved, as step criteria have not been met. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-one have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-one (J7325).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for hospital discharge day management; more than 30 minutes (CPT Code 
99239) provided on March 21, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 CPT code 99239 is supported in the 
medical record. Review of the file shows the hospital discharge day management; more than 30 minutes (CPT 
Code 99239) provided on March 21, 2020, is supported in the records. The discharge summary states the 
provider had a total visit time over 35 minutes with the patient. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
hospital discharge day management; more than 30 minutes (CPT Code 99239) provided on March 21, 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing services provided from 
April 8, 2020, to May 4, 2020. 
 
You asked the Plan to waive the copayment for the skilled nursing services. You say that you believe you have 
been overcharged. 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 a $0 
copayment per day for days 1 to 20, and a $178 copayment per day for days 21 to 100 for Skilled Nursing 
Facility (SNF) care. This SNF stay lasted 26 days, resulting in a total copayment amount of $1,068. 
 
You have been asked to pay a $0 copayment per day for days 1 to 20, and a $178 copayment per day for days 
21 to 100 for the skilled nursing services. the skilled nursing services falls within the Skilled Nursing Facility 
(SNF) care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing services 
provided from April 8, 2020, to May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the bone graft (D7953), and the implant removal 
(D6100) provided on July 2, 2020. 
 
You asked the Plan to reimburse you for the bone graft and implant removal. You say that your plan covers up 
to $1,000 for dental services. You say that something this serious should be covered. You say that this was an 
unexpected emergency. You also say that you should be reimbursed up to your annual benefit amount. The 
Plan denied your request. The Plan says implant services are excluded from coverage. 
 
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. The record indicates that you had a dental implant which was "deemed 
hopeless" and therefore the implant was removed and a site preservation graft was placed in order to prepare 
the site for an implant replacement. Therefore, we decided that the Plan does not have to reimburse you for the 
bone graft (D7953), and the implant removal (D6100) provided on July 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests provided on July 23, 2020. 
 
You asked the Plan to pay for the laboratory tests. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 laboratory tests provided on July 23, 2020.
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 the enrollee cannot be adequately cared 
for at a skilled nursing facility, and will require aggressive pulmonary hygiene. 
 The Plan denied your request. The Plan says the enrollee can receive care at a lower level of 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 physician 
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for an 
unwitnessed, but presumed, traumatic brain injury. The enrollee was intubated/ventilated and subsequently 
received a tracheotomy. He enrollee has been weaned from the ventilator to a tracheotomy collar. There is no 
evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed 
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for an injection provided by a participating 
provider. 
 
You asked the Plan to waive the co payment for an injection. You say that you do not agree with this. The Plan 
denied your request. The Plan says the correct co payment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 
co payment for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay $20 which is less than your co payment amount of $50 co payment for an injection. 
An injection falls within the Medicare Part B prescription drugs/in-network 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 co payment for an injection provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Volara system. You asked the Plan to pre-approve the requested device. You say that the system delivers hospital-level oscillation and lung expansion therapy in the home-setting. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the breathing help, and she already has a standalone nebulizer. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a nebulizer, and has been pre-approved for an oscillation device. These items serve the same purpose as the requested device. The requested device offers features that are not considered necessary to treat the enrollee. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a Volara system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient care provided from October 7, 
2019, to October 21, 2019. 
 
You asked the Plan to waive the copayment for inpatient care. You say that you believe the hospital is 
overcharging. The Plan denied your request. The Plan says this processed 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 $275 
copayment for per day for days 1-5 of inpatient hospital care, and $0 each day for days 6-90.  
 
You have been asked to pay a $1,375 copayment for inpatient care ($275 per day x 5 days = $1,375). 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 care provided from October 7, 2019, to October 
21, 2019.