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

We decided that the Plan does not have to pre-approve continued rental of the CPAP device (CPT Code 
E0601). 
 
You asked the Plan to pre-approve the CPAP device. You say that the device is necessary. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
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 CPAP device. Our physician 
reviewer found criteria for continued coverage of CPAP are not met. You were diagnosed with sleep apnea, 
and was started on CPAP in early 2019. You were seen in follow-up in October, and were not compliant with 
use at that time. Changes were made to address the compliance issue. However, there is no evidence of device 
use or further follow-up since November 2019. The CPAP is considered not medically necessary because it is 
not being used, and the denial is upheld. 
 
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 CPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued rental of the CPAP device (CPT Code E0601).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee would 
benefit from continued physical therapy sessions because of her cognitive decline. You say that physical 
therapy allowed her to maintain a stable gait and prevent physical decline. The Plan denied your request. The 
Plan says 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 10 additional physical therapy 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 the enrollee has had therapy for this 
condition and has been trained in an independent exercise program. Our reviewer says that the unique skills of 
a professional therapist are not required to safely and effectively provide ongoing treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture, complete mandibular 
denture, and two removals of residual tooth roots. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures and removals of residual 
tooth roots. You say that the enrollee will require a complete upper and lower denture due to missing teeth. The 
Plan denied your request. The Plan says these services are not covered under the enrollee's plan. 
 
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 
complete maxillary denture, complete mandibular denture, and two removals of residual tooth roots.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3330). 
 
You asked the Plan to pre-approve the endodontic therapy. You say that you feel this service should be 
covered. The Plan denied your request. The Plan says this service is not covered by your plan. 
 
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 
endodontic therapy (D3330).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea swim spa.You asked the Planto pre-approvethe item. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 Plandoes not haveto pre-approvea swim spa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this 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. 
 
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 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids provided on January 15, 2020.You asked the Plan to pay forthe hearing aids. You say that the issue has created a hardship for you.The Plan denied your request. The Plan says the maximum benefit has been exhausted.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. The records show that the claim was reprocessed correctly, and the Plan paid the maximum benefit for the provided hearing aids. Based on this information, we decided that the Plan's rules for coverage have not been met.Therefore, we decided that the Plan does not have tofurtherpay forthe hearing aids provided on January 15, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthroscopy, removal or shaving of knee joint cartilage using 
endoscope coded as 29877, 29880, 29881. 
 
You asked the Plan to pre-approve the arthroscopy. You say that you're requesting approval of the surgery and 
the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says 
that the documents do not support the reasonable and necessary criteria. 
 
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 arthroscopy. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare coverage criteria have been met to support arthroscopic surgery in the setting of 
function-limiting pain, clinical findings consistent with imaging evidence of a meniscal tears, radiographic 
evidence of less severe degenerative arthritis, and failure of reasonable conservative treatment. Therefore, this 
enrollee meets Medicare criteria for the requested right knee arthroscopic surgery. 
 
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 arthroscopy have been met. Therefore, we decided that the Plan has to pre-
approve arthroscopy, removal or shaving of knee joint cartilage using endoscope coded as 29877, 29880, 
29881.  
 
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 pay for the preventive procedure provided on June 16, 2020. 
 
You asked the Plan to pay for the preventive procedure. You say that you were told that this dentist was in-
network with your plan. The Plan denied your request. The Plan says this service is 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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure provided on June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implant body placement (D6010) and 
vestibuloplasty (D7350). 
 
You asked the Plan to pre-approve the implant body placement (D6010) and vestibuloplasty (D7350). You say 
that you need this procedure to be able to wear your partial. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
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 the 
implant body placement (D6010) and vestibuloplasty (D7350).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory service. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe outpatient radiology services provided on February 6, 2020.You asked the Plan to waive the cost share forthe services provided. You say that you thought the procedure would be covered.The Plan denied your request. The Plan says the claim was not denied, and processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance up to a copay maximum of $250 for diagnostic procedures. The file shows that you receivedheart imaging services. You have been asked to pay a 20% coinsurance for the services provided. The services fallwithin the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 cost share forthe outpatient radiology services provided on February 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided on September 17, 2019. 
 
You asked the Plan to pay for the assistant surgeon services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says assistant surgeon services are not payable for these 
procedures. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 
64581, 64590. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. 
This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be 
paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services 
have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services 
provided on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a nebulizer (E0570) received on March 26 
to June 26, 2020. 
 
You asked the Plan to waive the coinsurance for a nebulizer. You say that you returned and did not use the 
equipment in question. 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 Medicare-covered durable medical equipment items.  
 
You have been asked to pay $1.52, or 20% of the Plan-allowed amount of $7.61, per month for 4 months for a 
nebulizer. A nebulizer falls within the "Durable Medical Equipment (DME) and Related Supplies" 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 coinsurance for a nebulizer (E0570) received on March 26 to 
June 26, 2020.  
 
Your complaint about the provider billing you incorrectly is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits (99215) provided on 
September 2, 2020, and September 3, 2020. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you should not have 
copayments for these visits because you were in the hospital. The Plan denied your request. The Plan says these 
visits processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for services obtained from a specialist.  
 
You have been asked to pay a $40 copayment for each specialist office visit. 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 office visits (99215) provided on September 2, 2020, and September 3, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentforinpatient services provided from March 23, 2020, to March 26, 2020.You asked the Plan to waive the copayment forthe inpatient services. You say that the medical problem should have been found during the previous admissionso there should not be another copayment.The Plan denied your request. The Plan says you were charged this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Thecontract with the Plan clearly says that the enrolleemust pay a $300 copayment per day for days 1-5 for Inpatient Hospital Care. You have been asked to pay a $300 copayment per day for days 1-5 for the inpatient services.The inpatient services fall within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient services provided from March 23, 2020, to March 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on July 28, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you are on disability and you cannot 
afford this copayment. 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/in-network/CY scan.  
 
You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/in-network/CY scan 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 CT scan 
provided by a participating provider on July 28, 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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for surgery to correct a prosthetic hip dislocation. Medical problems are stable. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The 
patient does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and 
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not 
a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (CPT Code 22845), (22551), (20930), (22552) and 
(22853). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the criteria are not met. There is no correlation between imaging and physical exam. There is 
no instability. Therefore, the fusion surgery is not needed. 
 
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 (CPT Code 22845), (22551), (20930), (22552) and (22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950) and endodontic therapy (D3320). 
 
You asked the Plan to pre-approve the core buildup (D2950). You say that the enrollee wants to save the tooth. 
You say that you recommend a root canal and buildup. The Plan denied your request. The Plan says core 
buildup must be performed with a crown. 
 
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, core buildup must be provided together 
with a crown. A crown is not being requested. Therefore, we decided that the Plan does not have to pre-
approve core buildup (D2950) and endodontic therapy (D3320).