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

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260). 
 
You asked the Plan to pre-approve this item. You say that a semi-electric hospital bed is medically necessary. 
The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of a semi-electric 
hospital bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met. Specifically, the record does not show that you require frequent 
changes in body positioning only achievable with a semi-electric hospital bed. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a 
participating provider on February 7, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this was a follow-up and 
you should not be charged. 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 $40 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay $26.88 which is less than your copayment amount of $40 for a specialist office 
visit. A specialist office visit falls within the physician/practitioner services/specialist 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 specialist office visit provided by a participating provider 
on February 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve complete denture - maxillary. You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service 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. The services covered by the 
Plan are listed in the Plans Dental Handbook. 
 
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. Specifically, the service is not listed in the Plans EOC as a covered 
benefit. Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary 
(D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a thrombectomy (34203) provided February 5, 2020. 
 
You asked the Plan to pay for the thrombectomy. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the services billed. 
 
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 34203 is Embolectomy or thrombectomy, with or without 
catheter, popliteal-tibio-peroneal artery, by leg incision. 
 
We find that CPT code 34203 is not supported in the medical record. Specifically, the operative report 
documents a "remote thrombectomy" it does not specifically detail the procedure or a leg incision. Based on 
this information, we decided that Medicare rules for coverage of the thrombectomy have not been met. 
Therefore, we decided that the Plan does not have to pay for a thrombectomy (34203) provided February 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on July 9, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.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 forphysician services provided on July 9, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the pathology services. You say that this should be paid because your Plan 
doesn't offer the latest technology, which is MRI-guided biopsy.  You say that this would have been paid for 
had your network urologist done the biopsy.  You say you are only asking for the pathology services to be 
covered. The Plan denied your request. The Plan says these pathology services were neither ordered nor 
rendered by a Plan provider.  You did not have authorization from either the Plan or a Plan provider to have 
these pathology services. The Plan says that unauthorized, non-plan care is not covered. 
 
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 
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 pathology services provided by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for test materials and equipment for home INR monitoring 
(G0249) provided August 23, 2019 to September 6, 2019. 
 
You asked the Plan to pay for the test materials and equipment for home INR monitoring. You say that these 
services were medically necessary. The Plan denied your request. The Plan says the claim was not filed 
correctly. 
 
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 G0249 is not supported in the medical record. Specifically, Medicare rules do not allow 
billing this code earlier than 25 days. Based on this information, we decided that Medicare rules for coverage 
of the test materials and equipment for home INR monitoring have not been met. Therefore, we decided that 
the Plan does not have to pay for test materials and equipment for home INR monitoring (G0249) provided 
August 23, 2019 to September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 did not pre-approve the service 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 July 15, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient post-stabilization care provided from May 24,
2018, to May 26, 2018.
You asked the Plan to pay for the inpatient care. You say that the services provided were medically necessary.
The Plan denied your request. The Plan says the care provided was unauthorized post-stabilization care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 pay for the inpatient care. Our reviewer says that the
inpatient care provided was not medically necessary. Our physician reviewer found there was no
documentation provided necessitating post stabilization care services May 24, 2018, to May 26, 2018, at the
non-Plan facility. The treating physician did not document (in the physician notes, on a form, or in an order)
that the patient was not stable for transfer on any dates of 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 the inpatient care have not been met. Therefore, we decided that the Plan does
not have to pay for the inpatient post-stabilization care provided from May 24, 2018, to May 26, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a non-participating dentist. 
 
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 available from participating providers. 
 
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 supplemental 
dental benefits from a participating provider only. 
 
We looked at the file and Medicare rules. The file shows that the requested provider is not participating with 
the Plan. Based on this information, we decided that the Plan's rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a referral to a non-participating 
dentist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Shingles vaccine provided on July 23, 2020. 
 
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says the service is not 
covered by your medical plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on April 14, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you did not see the 
doctor. 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 $15 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $15 copayment for specialist telehealth services. Evidence was provided to show 
that the correct copayment has been applied. Specialist telehealth services falls within the 
physician/practitioner services/in-network/specialist 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 specialist telehealth services provided by a participating provider on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroutpatient surgery performed on July 2, 2020.You asked the Plan to waive the coinsurance foroutpatient surgery. You say thatyou did not see a need to question your quick release from the hospital and were not aware of the exaggerated billing consequences.The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each Medicare-covered outpatient hospital surgery. You have been asked to pay $4,656.04, or 20% of the Medicare-allowed amount of $23,280.18, for outpatient surgery. 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 foroutpatient surgery performed on July 2, 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 most appropriate level of care for the 
enrollee is an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH 
care have not been met. 
 
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. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
CoViD-19.  The enrollee was intubated/ventilated and subsequently received a tracheotomy.  The enrollee 
remains ventilated due to altered mental status but has been deemed stable for care outside of the intensive care 
unit (ICU).  There is no evidence that the enrollee requires services that are not currently available.  There is no 
advantage in transferring the enrollee to the LTACH.  The enrollee can remain at the current ACH until such a 
time that no acute services are required.  The enrollee can then be transferred/discharged to a lower level of 
care for any ongoing long-term care needs. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray of the left hand (73130-26-LT) provided. 
 
You asked the Plan to pay for an x-ray of the left hand. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code 73130-26-LT is not supported as billed. Specifically, the LT modifier indicates this was 
performed on the left side, but the billed diagnosis, S62.642A, nondisplaced fracture of proximal phalanx of 
right middle finger, initial encounter for closed fracture, specifies the right side. Based on this information, we 
decided that Medicare rules for coverage of an x-ray of the left hand have not been met. Therefore, we decided 
that the Plan does not have to pay for an x-ray of the left hand (73130-26-LT) provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880). 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
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 duplex scan of extracranial arteries. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found in this case the enrollee is asymptomatic and her physical exam is 
normal. There is no specific clinical rationale for the requested study. The review has determined that the 
requested duplex scan of extracranial arteries is not medically necessary or reasonable. 
 
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 duplex scan of extracranial arteries have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880).
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve an additional 10 physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the additional PT. You say that it is felt that continuation is necessary to 
allow for additional gains. The Plan denied your request. The Plan says that the enrollee has not had objective 
improvement from 10 sessions. This means that PT is not necessary for his condition. 
 
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. Our reviewer says 
that the documentation shows that continued PT is considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee is a 78-year-old male with a past medical history of hypertension 
and lumbar radiculopathy who has been receiving physical therapy treatments for pain, stiffness and unstable 
balance. He has received ten physical therapy treatments and ten more treatments have been requested. 
 
Although there is no documentation of improvement in strength or range of motion, there is documentation of 
improvement in balance test anterior reach and length of musculature acting on neutral spinal position, and 
there is documentation of improvement in the ability to navigate a flight of stairs and the frequency of near fall 
episodes. There is documentation of a decrease in lumbar and lower extremity pain from 6/10 to 2/10 on the 
visual analog scale. The documentation supports that an additional 10 visits are medically reasonable and 
necessary for this enrollee's condition. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve an additional 10 physical therapy (PT) visits.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the face down recovery system rental 
provided from January 1, 2020, through January 8, 2020. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not covered under your contractual 
policy or by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that these devices are statutorily non-covered because 
they do not fall within a Medicare benefit category. These types of devices are considered "precautionary 
devices" and also can be used for purposes other than the treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this item have not been met. Specifically, these devices are statutorily non-covered because they do 
not fall with a Medicare benefit category and can be used for purposes other than treatment of an illness or 
injury. Therefore, we decided that the Plan does not have to issue reimbursement for the face down recovery 
system rental provided from January 1, 2020, through January 8, 2020.