Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the injection of diagnostic or therapeutic 
substance provided on August 14, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that you have never paid this much for 
this procedure previously. The Plan denied your request. The Plan says that cost sharing is a contractual 
obligation under the plan and cannot be waived. 
 
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 $350 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay a $350 copayment for these services. These services fall within the Medicare-
covered surgery or other services provided to you at an outpatient hospital 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 injection of diagnostic or therapeutic substance provided on 
August 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture (D5213) and lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the upper partial denture and lower partial denture. You say that these 
services are medically necessary for your condition. The Plan denied your request. The Plan says you have 
exhausted your benefit for the services received. 
 
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 upper 
partial denture and lower partial denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that you last received partial upper dentures and 
partial lower dentures in November 2019. Therefore, you have exhausted your benefit for these services until 
November 2023. Based on this information, we decided that the Plan's rules for coverage of the upper partial 
denture and lower partial denture have not been met. Therefore, we decided that the Plan does not have to pre-
approve the upper partial denture (D5213) and lower partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS system for the enrollee. 
 
You asked the Plan to pre-approve a CardioMEMS system. You say that this system will allow you to better 
monitor and manage those symptoms that lead to repeat heart failure hospitalizations. The Plan denied your 
request. The Plan says that this service is considered experimental and investigational. 
 
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 a CardioMEMS system. Our reviewer 
says that a CardioMEMS system is not considered medically reasonable and necessary in this case. In this 
circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in 
only one randomized prospective trial to help reduce hospital readmission compared to standard medical 
therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. 
Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and 
not recommended in current guidelines for the treatment of heart failure. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of a CardioMEMS system. 
 
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 CardioMEMS system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 4 PWC is not covered. 
 
We looked at the file and Medicare rules. The item at issue is a Group 4 PWC. This item is not covered by 
Medicare. Therefore, we decided that the Plan does not have to pre-approve a Group 4 power wheelchair 
(PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on 
January 21, 2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 physician services provided 
to the enrollee out of network on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthoses provided on September 17, 2020. 
 
You asked the Plan to pay for knee orthoses. You say that this claim falls under very specific guidelines for 
medical necessity and should be recognized as such. The Plan denied your request. The Plan says the denial of 
payment for these items is correct, because the proof of delivery submitted is not itemized to verify the codes 
billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for DMEPOS items 
to determine whether payment is due.  
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the specific items billed on this claim. Based on this information, we decided that Medicare rules 
for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for 
knee orthoses provided on September 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a lumbar interspinous process 
stabilization device without decompression or fusion. 
 
You asked the Plan to pre-approve the insertion of a lumbar interspinous process stabilization device without 
decompression or fusion. You say that the enrollee has suffered for over 30 years and this has greatly impacted 
his quality of life. You say that the enrollee has not found relief through other approaches. You say that the 
procedure would be least invasive and provide the relief that is needed. The Plan denied your request. The Plan 
says the efficacy of the requested procedure has not been established. The Plan says that the requested service 
is not considered medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the insertion of a lumbar interspinous 
process stabilization device without decompression or fusion. Our reviewer says that the insertion of a lumbar 
interspinous process stabilization device without decompression or fusion is not considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee does not have any spinal 
instability and hardware is not needed. Our physician reviewer found that the spacer is considered 
experimental. More research is needed to show safety and efficacy. 
 
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 insertion of a lumbar interspinous process stabilization device without 
decompression or fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve 
the insertion of a lumbar interspinous process stabilization device without decompression or fusion.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on June 1, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all 
necessary covered services to the beneficiary either directly or under arrangements made with outside 
providers. Payment for this service would have been included under the facility claim. Payment to you for this 
service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay 
for imaging services provided to the enrollee on June 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of an ankle fracture after a motor vehicle collision. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 29, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that your in-network physician was unable to 
treat the enrollee. The Plan denied your request. The Plan says prior authorization was not obtained as required. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. 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 the medical services provided on September 29, 2020 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 15, 2020, by an 
out-of-network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider is out-of-network with the member's Plan, the services were not 
approved in advance and the services were not urgent or emergent. 
 
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 September 15, 
2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-treatment of a previous root canal (D3348), the 
treatment of a root canal obstruction (D3331), and the consultation (D9310) provided on September 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that your face was swollen. You say that you were 
advised you needed a re-treatment of a root canal that you had more than 15 years prior. You say that you are 
on a fixed income. You say that this was a cost effective treatment. You also say that you have been paying out 
of pocket for this expense. The Plan denied your request. The Plan says the re-treatment of a previous root 
canal is not listed as a covered service. The Plan says treatment of a root canal obstruction is not listed as a 
covered service. The Plan also says the consultation is 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 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 re-
treatment of a previous root canal (D3348), the treatment of a root canal obstruction (D3331), and the 
consultation (D9310) provided on September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CPAP sanitizer (A9270). 
 
You asked the Plan to pre-approve the CPAP sanitizer. You say that you would like reconsideration because 
you use your CPAP every night and are suffering from chronic sinus infections and severe allergies. The Plan 
denied your request. The Plan says the requested device does not directly treat a medical condition and is 
considered to be hygienic equipment 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the CPAP sanitizer (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you would like approval for these services 
to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers 
available for these services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physician services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0367). 
 
You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied 
your request. The Plan says cone beam CT capture and interpretation is 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 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 pre-approve a 
cone beam CT capture and interpretation (D0367).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for a lightweight motorized power wheelchair 
purchased online on January 6, 2020. 
 
You asked the Plan to reimburse you for this purchase. You say that you believe the Plan should pay for this 
equipment. The Plan denied your request. The Plan says this equipment was purchased from a provider who is 
not a Medicare eligible provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided by a physician or provider who is not eligible to accept Medicare payment. The 
Plan contract says that prior authorization is required for durable medical equipment. You purchased this 
equipment online from a provider is not a Medicare eligible provider. You did not have prior authorization for 
the purchase of this equipment. You did not follow the Plan contract rules when you purchased this equipment.  
Therefore, we decided that the Plan does not have to reimburse you for a lightweight motorized power 
wheelchair purchased online on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no literature to indicate that this drug is a effective first line treatment. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found this is a non-metastatic 
disease. Per the compendia, the requested drug is approved second line for MSI metastatic gastric cancer and 
third line for PDL1+ gastric cancer. There is no role for this drug as a first-line therapy. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says continuation of treatment past the approved visits is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

The file shows that 16 physical therapy visits were requested. The Plan has agreed to pre-approve 10 visits. 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 additional physical therapy services. Our physician reviewer found that there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. There is no documentation that the unique skills of a professional therapist are required to provide treatment, or that the services can be performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition, or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.