Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a sleep study (CPT 95811) for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says that this was partially approved, as CPT 95810 can be approved.
The Plan must follow Medicare rules. Medicare rules say that sleep studies 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 study. Our reviewer says that the requested study is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is suspected of having OSA, based on the laboratory finding of polycythemia as well as snoring and observed apneas. A spit-night PSG, with PAP titration, is the most appropriate test for this enrollee. If the diagnostic portion of the study is not sufficient for diagnosis, then that portion of the study is continued, and the titration is not done. If OSA is diagnosed in the first part of the test, then titration is attempted, potentially avoiding a separate titration study. CPT 95811 is considered reasonable and 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 study have been met. Therefore, we decided that the Plan has to pre-approve a sleep study (CPT 95811) 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
March 11, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that this nursing facility stay 
was medically necessary. The Plan denied your request. The Plan says the copayment amounts the enrollee is 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay $30 copayment for each in-network outpatient rehabilitation visit. There were 12 visits, resulting in a 
total copayment obligation of $360. 
 
The enrollee has been asked to pay $30 copayment for each physical therapy visit. Physical therapy visits fall 
within the Outpatient Rehabilitation Services benefit category. This means that the enrollee has been asked to 
pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayments for physical therapy visits provided from March 11, 2020 to March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor with an AC adapter.
You asked the Plan to pre-approve the monitor. You say that you had surgery twice on your heart in the past, therefore you are required to monitor your blood pressure level several times per day. 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 covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor with an AC adapter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a primary care visit provided on February 29, 2020. 
 
You asked the Plan to waive the copayment for office visit. You say that you did not receive this service. The 
Plan denied your request. The Plan says that the copayment amount you are being charged is correct. 
 
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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. 
Your contract with the Plan says that enrollees must pay $20 copayment for in-network primary care visit. 
 
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 provide any records to support that you received the billed 
services on this date of service. You say that you did not receive this service. Without supporting records, the 
Plan has not shown that its decision to hold you responsible for a $20 primary care copayment is correct or 
justified according to the Plan contract. Therefore, we decided that the Plan has to waive the copayment for a 
primary care visit provided on February 29, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral breast revision surgery. 
 
You asked the Plan to pre-approve the breast revision surgery. You say that you would like reconsideration 
because you are suffering from medical and self-esteem issues. The Plan denied your request. The Plan says 
this procedure is cosmetic in nature. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 breast revision surgery. Our 
reviewer says that you do not have evidence of a significantly abnormal appearance that would qualify for 
reconstructive surgery. Cosmetic surgery is performed to reshape normal structures of the body or improve 
appearance and self-esteem. Based on the medical documentation from the requesting surgeon and therapist 
letter, the planned surgeries are consistent with this definition of cosmetic surgery. Our reviewer found you do 
not have documentation of a mechanical complications of the breast prostheses or other functional 
impairments. Therefore, the requested surgeries do not satisfy Medicare medically necessary criteria. 
 
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 breast revision surgery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve bilateral breast revision surgery.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays you received on March 5, 2020. 
 
You asked the Plan to pay for the periapical x-rays. You say that you were not aware that x-rays are not 
covered. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 services are not among 
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. 
Periapical x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the periapical x-
rays you received on March 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. The Plan denied your request. The Plan says the additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that there is no documentation that the 12 additional requested physical therapy visits are generally accepted as specific and effective therapy for the enrollee's condition. There is no documentation that the enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on March 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that for enrollees who are registered hospital 
inpatients or outpatients, the inpatient or outpatient hospital POS code should be reported.  
 
We looked at the file and Medicare rules. The anesthesia services were billed with an outpatient POS code. The 
records show that the enrollee was under inpatient status when the anesthesia services were provided. This 
means that the services must be billed with an inpatient POS code. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the anesthesia services provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for physician services ($10 each visit) and emergency room services ($25 each visit) provided from January 6, 2020 to February 5, 2020.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct. The Plan denied your request. The Plan says these copayments were charged based on the services provided and your 2020 Plan contract.
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 $10 copayment for physician visits and $25 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 copayments charged for physician services ($10 each visit) and emergency room services ($25 each visit) provided from January 6, 2020 to February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an artificial leg with advanced knee and foot features.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested K3 prosthesis exceeds the enrollee's needs and cannot be covered.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found at this time, the documentation does not support that the the enrollee is at a K3 functional level or above
at this time. He does not have the ability to traverse most environmental barriers and does not have vocational,
therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an artificial leg with advanced knee and foot features.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure monitor.
You asked the Plan to pre-approve the monitor. You say that if you know that your blood pressure is high, you can get to a doctor. 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 covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 22 and 27. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says the teeth do not 
appear to have significant breakdown. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
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 crowns. Our reviewer says that the 
crowns do not meet coverage criteria. Our physician reviewer found documentation submitted does not show 
significant coronal breakdown due to caries or fracture of teeth #22 and 27 to warrant crown restorations 
(D2750). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not 
have to pre-approve crowns (D2750) for tooth #'s 22 and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit (99214). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 the medical services provided on April 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is only required for shopping, bank visits, and post office visits. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 scooter. Our reviewer says that the 
requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation 
does not support that you have a personal mobility deficit that impairs participation in MRADLs. The enrollee 
is able to use a walker inside the house but cannot ambulate more than about 100 feet. She depends on a 
scooter to go shopping and to go to appointments. 
 
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 scooter have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit (99336). You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits.
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 the medical services provided on March 3, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the diagnostic colonoscopy (45378) 
provided on September 13, 2019. 
 
You asked the Plan to waive the coinsurance for this service. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied 
correctly to the service provided. 
 
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% 
coinsurance of the cost for each outpatient hospital and ambulatory surgery visit.  
 
You have been asked to pay a $184.27 coinsurance ($921.36 allowed amount x 20% coinsurance) for the 
ambulatory surgery provided. 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 diagnostic 
colonoscopy (45378) provided on September 13, 2019.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve additional treatment doses ofradiation therapy for breast cancer for 
the enrollee. 
 
You asked the Plan to pre-approve the additional doses. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for more than 28 daily treatment doses exceeds the limit. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 additional doses. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found according to the NCCN guidelines, it is important to individualize radiation planning and 
delivery. Although it is standard to received 25-28 doses to the whole breast with a boost in 4-8 fractions, this 
enrollee will be receiving both in 30 treatments which is more convenient to the enrollee. The service is 
reasonable and 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 additional doses have been met. Therefore, we decided that the Plan has to 
pre-approve additional treatment doses ofradiation therapy for breast cancer 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.