Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional eight (8) PT visits. 
 
You asked the Plan to pre-approve the additional eight (8) PT visits. The Plan denied your request. The Plan 
says based on the documentation, treatment is such that it has become redundant consisting of sitting 
therapeutic exercises, standing endurance tolerance, and a walking program. This can be transitioned to a 
functional maintenance program with similar outcome expected. If there is significant change in your 
functional status, either improved or declined, another episode of care would then be warranted. Therefore, we 
authorized an additional 2 PT visits for transition to home exercise program. 
 
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 eight (8) PT visits. Our 
reviewer says that skilled services are not medically necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is 
not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for 
this condition and it does not appear that you require the unique skills of a professional therapist to safely and 
 
 
effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or 
under the supervision of a therapist. You have staff assist at your facility and you can ambulate with staff. 
The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design 
and/or deliver a program to maintain your 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 the additional eight (8) PT visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an additional eight (8) PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an alveoplasty (D7320) performed on July 14, 2020. 
 
You asked the Plan to pay for an alveoplasty. You say that you were unaware that this service was not covered 
and that the dental provider did not know the cause of your discomfort until the provider actually cut into the 
gum. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 an 
alveoplasty (D7320) performed on July 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the electric osteogenesis stimulator, non-
invasive (E0748) provided May 6, 2020. 
 
You asked the Plan to waive the coinsurance for the osteogenesis stimulator. You say that you were on pain 
medications from your surgery the day prior and was not fully competent while signing the e-forms for the 
equipment. The Plan denied your request. The Plan says the claim was processed and the correct coinsurance 
was applied per the plan benefits. 
 
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 and related supplies for Durable medical 
equipment (DME) and related supplies.  
 
You have been asked to pay $904 ($4520.00 x 20%) for the osteogenesis stimulator. The osteogenesis 
stimulator 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 the electric osteogenesis stimulator, non-invasive (E0748) 
provided May 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer. 
 
You asked the Plan to pre-approve Insertion of Interlaminar/Interspinous Process Stabilization/Distraction 
Device (22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870). 
You say that this is the most appropriate treatment for the enrollee. The Plan denied your request. The Plan 
says the Superion interspinous spacer procedure 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 Insertion of Interlaminar/Interspinous 
Process Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process 
Stabilization/Distraction Device (22870). Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found the Verteflex device 
is experimental. More research is needed to show safety and efficacy. There is no documented spinal 
instability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device 
(22869) and Insertion of Interlaminar/Interspinous Process Stabilization/Distraction Device (22870) have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous 
decompression spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network 
provider. 
 
You asked the Plan to pre-approve a second opinion with an out of network provider. You say that you want to 
see an out of network provider for a second opinion. The Plan denied your request. The Plan says you do not 
have a benefit for out of network 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second 
opinion to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided by an OON 
provider. 
 
You asked the Plan to pay for an office visit. You say that these services are payable. The Plan denied your 
request. The Plan says rules for payment have not been met. 
 
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 by 
an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
January 8, 2020, through January 14, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you wanted to ensure that 
you are being billed the correct amount by the hospital. The Plan denied your request. The Plan says the claim 
was processed accordingly with your 2020 EOC benefits. 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 received inpatient hospital care provided from January 8, 2020, through January 14, 
2020. You were asked to pay a $200 copayment per day from January 8, 2020, through January 13, 2020, days 
1-6 of your inpatient hospital care. You were discharged on January 14, 2020, and there was no copayment 
charge for the day of discharge. Per your contract there is a $200 copayment per day required for days 1-7. 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 inpatient hospital care provided from January 8, 2020, 
through January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from June 11, 2020, 
through July 2, 2020. 
 
You asked the Plan to waive the copayment for wound debridement. You say that you have paid $35 for each visit for the 
same procedure at another wound clinic. You say that this is coded incorrectly because you were not having surgery. The 
Plan denied your request. The Plan says the copayments applied 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 $250 copayment 
for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not 
limited to hospital or other facility charges and physician or surgical charges. 
 
You have been asked to pay a $250 copayment for each wound debridement visit. The total amount you owe is $1,000 
($250/visit x 4 visits = $1,000). Wound debridement falls within the "Outpatient Surgery and Other Medical Services 
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound debridement is 
considered a surgical service. 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 wound debridement provided from June 11, 2020, 
through July 2, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy rendered on 
September 14, 2020. 
 
You asked the Plan to waive the copayment for these services. You say that this was your regularly-scheduled 
preventive colonoscopy. The Plan denied your request. The Plan says the copayment was applied 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 $200 
copayment for Medicare-covered outpatient hospital surgery services.  
 
Review of the file shows that you received a diagnostic colonoscopy on September 14, 2020. The services were 
diagnostic, and not screening, in nature because six polyps were removed. You have been asked to pay a $200 
copayment for these services. These services fall within the Medicare-covered outpatient hospital surgery 
services 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 diagnostic colonoscopy 
rendered on September 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you do not have financial resources for 
private transportation and have no assistance from your municipality. The Plan denied your request. The Plan 
says the denial of authorization for additional routine transportation is correct, because routine transportation 
beyond 20 one-way trips per year is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 20 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit rendered on August 10, 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 services are not covered when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted a 
claim for procedure code 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the 
office visit rendered on August 10, 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 based on the documentation provided, 
the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an 
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and 
regular physician evaluation. The enrollee's 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274), the initial periapical x-ray 
(D0220), and the additional periapical x-ray (D0230) provided on August 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that the Plan paid for these services for a previous 
date of service. You say that on the date of service in this case, you had more bitewing x-rays done and more x-
rays on teeth that did not get x-rayed at your last appointment. You say that these x-rays should be covered 
since they were covered before. The Plan denied your request. The Plan says 1 set of bitewing x-rays and 1 
periapical x-ray are covered per calendar year. The Plan says that the frequency limit 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 1 of each x-ray 
per calendar year has been exceeded. The record shows that the Plan paid for 1 set of bitewing x-rays and 1 
periapical x-rays that you received on June 12, 2020. Therefore, we decided that the Plan does not have to pay 
for the bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray 
(D0230) provided on August 7, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve chemo-denervation with botulinum toxin for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of botulinum toxin in the setting of lower limb 
dystonia have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found there is evidence within current peer reviewed literature that the drug is effective for focal lower 
extremity dystonia. It can be concluded that ample evidence exists to conclude that the proposed service is 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve chemo-denervation with botulinum toxin for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve an intralaminar epidural steroid injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the services requested do not meet the medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee could not afford to go to physical therapy. The physical exam shows a positive straight leg 
raising test and SI joint pain. The MRI shows multiple disc bulges. 
 
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 injection have been met. Therefore, we decided that the Plan has to pre-
approve an intralaminar epidural steroid injection for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of ocrelizumab (Ocrevus) at a dosage frequency of 
1mg to be delivered every 5 months. 
 
You asked the Plan to pre-approve ocrelizumab. You say that you believe that this drug every 5 months is 
appropriate and medically necessary. The Plan denied your request. The Plan says the denial of authorization 
for this drug at the requested dosing frequency is correct, because this exceeds the approved dosage frequency 
of 1mg per 6 months. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 ocrelizumab. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested dosage frequency of this drug. Our physician 
reviewer found ocrelizumab (Ocrevus) is approved by the Food & Drug Administration (FDA) for use as a 
disease modifying therapy for multiple sclerosis. The enrollee's treating physician has prescribed this drug to be 
infused every 5 months. However, the FDA-approved labelling for this drug only supports dosing every 6 
months. Likewise, the Medicare-approved compendia only support dosing every 6 months. In this setting the 
requesting change in dosing interval cannot be said to be 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 ocrelizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve use of ocrelizumab (Ocrevus) at a dosage frequency of 1mg to be delivered every 5 
months.