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

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair with accessories (K0843, 
E2377, E2311, E1007, E2313) 
 
You asked the Plan to pre-approve the group 2 power wheelchair. You say that the chair is medically 
necessary. The Plan denied your request. The Plan says the requested powerchair exceeds the needs of the 
enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that Group 2 power wheelchairs are covered when 
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 group 2 power wheelchair. Our 
reviewer says that the requested powerchair is not medically necessary. Our physician reviewer found the 
group 2 multiple power wheelchair to include power tilt/recline, power elevating leg rests, and upgraded 
electronics exceeds the patient's needs for mobility and positioning and is not medically necessary. The 
documentation submitted reveals the patient has a mobility deficit but is not clear specifically that it impairs 
activities of daily living in the home or that it is unable to be helped by a manual wheelchair or walker. 
 
 
 
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 group 2 power wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a group 2 power wheelchair with accessories (K0843, E2377, E2311, E1007, 
E2313)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of the Superion Interspinous stabilization 
device (22869). 
 
You asked the Plan to pre-approve this service. You say that insertion of the Superion Interspinous device is 
medically necessary as the member has lumbar spinal stenosis with neurogenic claudication. The Plan denied 
your request. The Plan says that medical studies have not proven that the device is effective. 
 
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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the spacer device is experimental. More research is needed to show safety and efficacy.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of the Superion Interspinous stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on 
February 20, 2020. 
 
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says the orthoses were not 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 pay for the knee orthosis (L1851) and suspension 
sleeve (L2397). Our reviewer says that the service orthoses were not medically necessary. Our physician 
reviewer found the enrollee's chief complaint was knee pain, as well as back pain, ankle pain, shoulder pain, 
and wrist pain. The documentation in the case file does not support that the requested knee orthosis and sleeve 
were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria 
established by the LCD. There is insufficient documentation of an examination of the enrollee, and there is 
insufficient credible objective documentation of joint laxity. 
The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met. 
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided 
on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3330). 
 
You asked the Plan to pre-approve the endodontic therapy. You say that these services are necessary for the 
enrollee. The Plan denied your request. The Plan says the service requested 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endodontic therapy (D3330).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on January 3, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that you already paid a $45 copayment. You 
say that the additional charge was not explained to you so you shouldn't be responsible. The Plan denied your 
request. The Plan says the copayment 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 $30 
copayment for Medicare-covered non-radiological diagnostic services.  
 
You have been asked to pay $21.48, which is less than the standard $30 copayment for the EKG. The EKG 
falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 
Outpatient diagnostic tests are considered a separate 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 the EKG provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Omnipod Dash. 
 
You asked the Plan to pay for the Omnipod Dash. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says Medicare Part D pays for 
mechanical or electronic insulin pumps that are not coverable under the Medicare Part B durable medical 
equipment (DME) benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that medical supplies directly associated with 
delivering insulin to the body not otherwise covered under Medicare Part B, can satisfy the definition of a Part 
D drug. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Omnipod Dash have not been met. Specifically, the requested equipment does not meet the 
definition of durable medical equipment as covered under Medicare Part B. Therefore, we decided that the Plan 
does not have to pay for the Omnipod Dash.  
 
Benefits for the Omnipod Dash may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prefabricated post and core in addition to a crown 
(D2954) for tooth # 5. 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to a crown. You say that the 
enrollee has severe erosion and more than 2/3 occlusal width on teeth # 20 and 29. You say that tooth # 13 has 
recurrent decay which will need a full coverage crown. You also say that tooth # 5 has recurrent decay under 
the original crown. The Plan denied your request. The Plan says prefabricated post and core in addition to a 
crown is not listed as a covered service. The Plan also says that any service not listed 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 pre-approve the 
prefabricated post and core in addition to a crown (D2954) for tooth # 5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiation therapy services provided on February 27, 
2020, by an out-of-network provider. 
 
You asked the Plan to pay for the radiation therapy services. You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says you did not request prior authorization. 
 
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 services at issue in this appeal. 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 radiation therapy services provided on February 27, 2020, by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services performed by a chiropractor from May 6, 2020, to 
July 29, 2020. 
 
You asked the Plan to pay for the services provided. You say that the treatment has been very beneficial. The 
Plan denied your request. The Plan says covered services only include manual manipulation of the spine to 
correct subluxation. 
 
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 file shows that office visits (99203 and 99213), mechanical traction (97012) and electrical stimulation 
(97014) were provided. Your plan only covers manual manipulation of the spine. Services other than manual 
manipulation of the spine, when performed by a chiropractor, are not covered. Therefore, we decided that the 
Plan does not have to pay for services performed by a chiropractor from May 6, 2020, to July 29, 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 enrollee has a new fracture, functional decline, and worsening spasticity. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.

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 physician reviewer found that the enrollee is at a minimal assist level for rolling, maximum assist for standing and bed-to-chair transfers, and she can propel a manual wheelchair with supervision. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. There are no complex medical needs that need an IRF admission. Liver function tests can be safely drawn at a lower level of care. She may benefit from multiple therapies, such as physical and occupational therapy, but the documentation does not support that her functional status requires an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 9, 2020, by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services rendered were non-emergent and performed by a provider who is not 
under contract with the Health Plan. 
 
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 July 9, 2020, by 
an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member's needs can be appropriate and safely address at a 
lower level of care. 
 
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. The patient 
appears to be improving and only requires short term additional acute care hospital services which can be 
completed at the current facility. The patient does not require services at the LTACH that are not already 
available at the current facility. Our physician reviewer found that the enrollee's condition does not meet 
Medicare criteria for LTACH services. 
 
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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 13, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided. 
 
You asked the Plan to pay for the ambulance services. You say that you were unable to leave your husband 
home alone and could not be transported The Plan denied your request. The Plan says these services are not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport service. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 22, 2020 to 
June 23, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the authorization was approved for 
observation. However, the inpatient stay was medically necessary. You request the authorization be updated to 
inpatient and the claim be reprocessed. The Plan denied your request. The Plan says the records do not meet 
clinical criteria for inpatient hospital care services. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the enrollee presented to the ER on 6/22/20 with fever, 
 
 
chills, cough, SOB, nausea and vomiting. On evaluation temp was 101 and the chest exam demonstrated basilar 
crackles. Labs revealed positive Covid 19, normal WBC, CPK 1591. The EKG was normal; CXR normal and 
Chest CT with peribronchial thickening. He was admitted to telemetry. He remained medically stable with 
excellent O2 saturations off supplemental oxygen and was discharged home 6/23/20 on oral antibiotics and 
instructions for quarantine x 14 days. The review has determined that the record did not show that at the time of 
inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided June 22, 2020 to June 23, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging, stress test and 
dose of tc-99m tetrofosmin provided on March 30, 2020. 
 
You asked the Plan to waive the cost for the myocardial perfusion imaging, stress test and dose of tc-99m 
tetrofosmin. You say that you paid $125 on the day of service. You say that it was not explained that you 
would owe more so you shouldn't have to pay. The Plan denied your request. The Plan says the cost share 
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 $30 
copayment for Medicare-covered non-radiological diagnostic services, 20% coinsurance for each Medicare-
covered medical supply and a $125 copayment for each Medicare-covered radiological diagnostic service.  
 
 
  
 
 
You have been asked to pay a total of $199.44 for the myocardial perfusion imaging, stress test and dose of tc-
99m tetrofosmin.  
 
Service Allowed Amount Standard Cost Member Liability 
Myocardial Perfusion Imaging $322.83 $125 $125 
Stress Test $55.11 $30 $30 
TC-99m Tetrofosmin $222.20 20% $44.44 
TOTAL:   $199.44 
 
The myocardial perfusion imaging, stress test and dose of tc-99m tetrofosmin fall within the "Outpatient 
Diagnostic Tests and Therapeutic Services and 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 cost for the myocardial perfusion imaging, stress test and dose of tc-99m tetrofosmin provided on 
March 30, 2020.