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

 
We decided that the Plan does not have to pre-approve an oximeter. 
 
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. The rules say that oximeters (E0445) are denied as non-covered. 
 
We looked at the file and Medicare rules. The item at issue is an oximeter. This item is denied by Medicare as 
non-covered. Therefore, we decided that the Plan does not have to pre-approve an oximeter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 140 units per month of high compression 
bandages. 
 
You asked the Plan to pre-approve the extra units. You say that this is medically necessary. The Plan denied 
your request. The Plan says Medicare only allows for unit per week. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers 40 units per month of 
compression bandages. 
 
The requested additional units exceed the benefit limit. Based on this information, we decided that Medicare 
rules for coverage of the extra units have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an additional 140 units per month of high compression bandages.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the ultrasound provided by an in-network 
provider. 
 
You asked the Plan to waive the coinsurance for the ultrasound. You say that the provider did the ultrasound 
without your knowledge and you should not be charged for it. The Plan denied your request. The Plan says the 
provider also confirmed that you were aware of the diagnostic test being performed and consented to the test. 
The Plan states it was noted that your provider had an approved authorization from the Plan for the diagnostic 
ultrasound of the pelvis under Authorization No. E02669996. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Review of the file show that you had the ultrasound, 
performed by an in-network provider. You are asked to pay 20% coinsurance for the ultrasound. Your EOC 
states that enrollees must pay 20% coinsurance for other in-network diagnostic procedures and tests such as 
MRIs, PET scans, CT scans, and other nuclear medicine. 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 ultrasound provided by an in-network provider.
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 based on the documentation provided, 
the health plan?s denial should be upheld. You do not require the intensity of services provided at an IRF. 
Specifically, you are not shown to require, or to be able to perform, fifteen hours per week of rehabilitative 
services with regular physician evaluation. Your care needs can be met at a lower level of care. 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a 
participating provider on June 22, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this was supposed to 
be $0. You say that this was routine. The Plan denied your request. The Plan says the correct copayment has 
been 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 $100 
copayment for outpatient diagnostic tests/diagnostic tests.  
 
You have been asked to pay a $100 copayment for a diagnostic mammogram. The mammogram that was 
provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic 
mammogram falls within the outpatient diagnostic tests/diagnostic tests benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a diagnostic mammogram provided by a participating provider on 
June 22, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 5, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that this should be considered 
preventative, not diagnostic. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $450 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers for outpatient surgery, including services provided at hospital outpatient facilities. 
 
The medical records show that you received a diagnostic colonoscopy on August 5, 2020. Therefore, you are 
responsible to pay the $450 copayment.   
 
You have been asked to pay a $450 copayment for a colonoscopy. A colonoscopy falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment 
 
You asked the Plan to pay for oxygen equipment. You say that the oxygen equipment should be paid for that 
you purchased. The Plan denied your request. The Plan says purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. The rules say that to qualify for coverage, the equipment must be rented 
not purchased.    
 
We asked our 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 oxygen equipment. Our reviewer says that the service is 
not covered. Our reviewer found the oxygen concentrator was purchased by the member. Medicare only covers 
rental of oxygen equipment, not purchases. The denial to reimburse for the oxygen equipment is upheld. 
Shipping services are not a medically necessary service that would benefit any medical treatment. In addition, 
LPT Medical is not a Medicare-certified provider. Therefore, we will also not reimburse the member for the 
shipping service.
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided that the Plan does 
not have to pay for oxygen equipment.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services provided on June 5, 2020. 
 
You asked the Plan to pay for the moderate sedation services (99152). You say that the Plan should pay this 
claim. The Plan denied your request. The Plan says the documentation submitted did not include sedation notes 
and does not indicate the presence of an independent trained observer. 
 
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, the CPT Code Manual definition of code 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older.  
 
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no record of an 
independent trained observer. Based on this information, we decided that Medicare rules for coverage of the 
moderate sedation services (99152) have not been met. Therefore, we decided that the Plan does not have to 
pay for the moderate sedation services provided on June 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial perfusion imaging. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
records do not say why the test is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiology testing is only covered under certain 
medical indications. 
 
We looked at the file and Medicare rules. In this case, there are insufficient medical records to show the results 
of the testing will be used to determine a specific diagnosis or treatment strategy. Based on this information, we 
decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have 
to pre-approve myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left sympathetic nerve block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is needed to treat neuropathic leg pain. The Plan 
denied your request. The Plan says this 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 the block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not have signs of complex regional pain syndrome, or sympathetically maintained pain. 
Therefore, there is no indication for a sympathetic nerve block. The request is deemed not medically reasonable 
or 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a left sympathetic nerve block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) and the screening of 
patient (D0190) provided on July 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that the denial that you received was deficient in 
information. You also say that you qualify under the Plan's "extra help" program due to low income. The Plan 
denied your request. The Plan says 2 exams per year are covered. The Plan says that 2 cleanings per year are 
covered. The Plan also says that the frequency limits for these services have been exceeded. 
 
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 limits of 2 exams and 2 
cleanings per year have been exceeded. The record shows that the Plan paid for 2 exams that you received on 
January 28, 2020, and May 29, 2020. The record shows that the Plan paid for 2 cleanings that you received on 
January 29, 2020 and May 29, 2020. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) and the screening of patient (D0190) provided on July 30, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve bunion surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no documentation of a failure of conservative therapy. 
 
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 surgery. Our reviewer says that the 
requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found 
in this particular case you are noted to have painful bunion deformities with confirmation of increased 
intermetatarsal ankle and hallux abductus angle on photocopies of x-rays. You are noted to have failed 
conservative treatment including wider shoes. Bunion surgery for a bunion that is painful is considered 
standard of care. For this reason, the right bunion correction for this patient should be considered medically 
reasonable and 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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve bunion surgery.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an evaluation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the evaluation and extraction. You say that you have a tooth that you need 
extracted by an oral surgeon. The Plan denied your request. The Plan says your contract with the Plan only 
provides coverage for dental services when they are performed by a participating general dentist. The Plan also 
says that dental services performed by an oral surgeon are not covered. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve an evaluation and extraction to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, 
E2377, E2313, E2300, K0108) for the enrollee. 
 
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not 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 additional accessories. Our reviewer 
says that the requested additional accessories are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is no documentation that the enrollee meets the criteria for the 
additional accessories. The seat lift mechanism is non-covered; the upgraded electronics are not covered as the 
power options can be controlled by their individual switches and the arm rests and head rest are included with 
the approved group 3 power wheelchair. 
 
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 accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2377, E2313, E2300, 
K0108) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test  results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation 
(D7953). 
 
You asked the Plan to pre-approve the dental service. You say that your dentures has been affected by the 
cancer treatment. You say that you have a major infection with a loss of bone for which a molar has to be 
extracted and place a bone replacement. You also say that the service was medically necessary and not done for 
cosmetic reasons. The Plan denied your request. The Plan says bone replacement graft for ridge preservation 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 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 pre-approve a 
bone replacement graft for ridge preservation (D7953).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Echo guide provided on June 23, 2020. 
 
You asked the Plan to pay for the Echo guide. You say that the Plan should pay this claim. The Plan denied 
your request. The Plan says this procedure is not substantiated in the clinical documentation. 
 
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, the CPT Code Manual definition of code 76942 is Ultrasonic guidance for needle placement (eg, 
biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  
 
We find that CPT code 76942 is not supported in the medical record. Specifically, the operative report did not 
include documentation of imaging supervision and interpretation of ultrasonic guidance for needle placement. 
Based on this information, we decided that Medicare rules for coverage of the Echo guide have not been met. 
Therefore, we decided that the Plan does not have to pay for the Echo guide provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2020. 
 
You asked the Plan to pay for the medical services. You say that the provider was Medicare credentialed on 
January 6, 2020. The Plan denied your request. The Plan says the provider was not credentialed to see the 
Plan's members until April 2020. 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 February 18, 2020.