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

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary for the enrollee in this case. The patient 
does have obstructive sleep apnea with thoracic restrictive disease. The provided records did not show that the 
patient would not be able to be treated effectively with a BiPAP (with AVAPS) machine that would supply the 
bilevel PAP which the patient requires. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for a portable ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services 
received April 7, 2020, to April 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you were 
never informed that you would have an additional copayment. The Plan denied your request. The Plan says the 
copayment applied correctly in this case. 
 
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 $325 
copayment each day for days 1 to 4, $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a total cost share of $1300 for the inpatient rehabilitation services ($325 x 4). The 
services provided fall within the inpatient hospital care 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 inpatient rehabilitation services received April 7, 2020, to April 14, 2020.  
 
Your complaint about the Plan's customer service potentially providing you with incorrect information 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 pay for the medical services provided on July 15, 2020, by an OON 
provider. 
 
You asked the Plan to pay for a provider office visit. You say that these medically necessary services were 
provided to the enrollee in good faith. 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 on July 15, 2020, by 
an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health visit provided on April 29, 2020. 
 
You asked the Plan to pay for the home health visit. You say that this was billed correctly on TOB 0323 which 
is for a continuing claim for per service visit. This is not for episodic payment. The Plan denied your request. 
The Plan says this was not billed with a correct TOB. 
 
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed using one of 
the TOBs listed above. 
 
TOB 0323 is not valid for Medicare billing of home health services. Therefore, we decided that the Plan does 
not have to pay for the home health visit provided on April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller 
(E2377) and expandable controller harness (E2313) for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that although there are three approved power options on this wheelchair, 
there is not a medical need to control these power options through the joystick. 
 
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 these items. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. The documentation does 
not reveal that the patient needs an expandable controller to operate other types of proportional input devices, 
non-proportional input devices, or to operate 3 or more powered seating actuators through the drive control. 
The documentation does not reveal the patient needs the expandable controller to operate a separate display, 
other electronic devices, or for an attendant control. The patient has sufficient upper extremity strength and 
functional ability to operate any power options through their own individual switches. Our physician reviewer 
found that the enrollee's condition does not meet criteria for these items. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), expandable controller (E2377) and expandable 
controller harness (E2313) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a leadless pacemaker (33274). You say that the requested leadless 
pacemaker is medically necessary. The Plan denied your request. The Plan says per Medicare guidelines, 
leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. In this case, Medicare guidelines say leadless pacemakers are non-
covered when furnished outside of a CMS approved CED study. The file does not show that the enrollee is to 
have the procedure performed under a CMS approved CED study. Based on this information, we decided that 
Medicare rules for coverage of a leadless pacemaker (33274) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a leadless pacemaker (33274).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis, resin-based composite, periodic oral 
evaluation, and to pay for the preventive procedure provided on June 16, 2020, and June 29, 2020. 
 
You asked the Plan to pay more for the prophylaxis, resin-based composite, periodic oral evaluation, and 
preventive procedure. You say that you should not be balance billed because you were not able to find a 
participating dentist. The Plan denied your request. The Plan says these services were rendered by an OON 
provider, and the cost share was processed correctly according to your contractual obligation. The Plan also 
says that the preventive procedure 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, unspecified preventive procedure not 
among those covered under this benefit. You are also responsible for the difference between the billed amount 
and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay more 
for the prophylaxis, resin-based composite, periodic oral evaluation, and to pay for the preventive procedure 
provided on June 16, 2020, and June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of a mini implant (D6013), the 
implant supported crown (D6065), the extraction (D7140), and the bone replacement graft for ridge 
preservation (D7953) provided on August 17, 2020. 
 
You asked the Plan to pay for the dental services. You say that your previous dentist who was a participating 
provider did a poor job with your crown. You say that you were a nervous wreck getting dental services and 
needed to see someone that offered sedation dentistry. You say that the provider in this case was wonderful and 
The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says 
that services are only covered when received by a participating provider. 
 
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, dental services that you receive out of 
network are not covered. Therefore, we decided that the Plan does not have to pay for the surgical placement of 
a mini implant (D6013), the implant supported crown (D6065), the extraction (D7140), and the bone 
replacement graft for ridge preservation (D7953) provided on August 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for  PTA services (G0157) provided on June 20, 2019. 
 
You asked the Plan to pay for the PTA services. You say that you would like reconsideration because the 
services rendered were medically necessary. The Plan denied your request. The Plan says the services of a PTA 
cannot be provided incidental to a physician/appropriately licensed other practitioner as they are not 
specifically qualified as licensed physical therapists. 
 
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 G0157 is not supported in the record. Specifically, the services of a physical therapy 
assistant shall not be billed as services incident to a physician/NPP's service, because they do not meet the 
qualifications of a therapist. Based on this information, we decided that Medicare rules for coverage of the PTA 
services have not been met. Therefore, we decided that the Plan does not have to pay for  PTA services 
(G0157) provided on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral 
facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical 
or thoracic; single level (CPT Code 64490) provided on July 16, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. CPT 64490-RT*1 and 64490-LT-
59*1 has an MUE value of 1 and MUE Adjudication Indicator is 2 but billed 2 units. Per the above 
guidelines, we find the Medicare rule for payment of this date of service July 16, 2020 claim has not been met. 
If the provider determines that a billing error occurred during the initial submission of the denied claim, the 
plan would accept a submission of a corrected claim to consider services for payment. Therefore, we decided 
that the Plan does not have to pay for injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; single level (CPT Code 64490) provided on July 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara for the enrollee. 
 
You asked the Plan to pre-approve Stelara. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Stelara for the enrollee.  
 
Benefits for Stelara 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 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 were not urgent or emergent, approved in advance and the provider is 
not 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 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 August 4, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 18, 
2020, through June 22, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. 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). The contract with the Plan clearly says that enrollees must pay a 
$275 copayment each day for days 1 to 5 for in-network, Medicare-covered hospital care. 
 
The enrollee has been asked to pay a $1,100 copayment for the inpatient stay. ($275/day x 4 days = $1,100). 
The inpatient stay falls within the "Inpatient Hospital Care" benefit category. This means that the enrollee has 
been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation that the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does 
not have to waive the copayment for the inpatient stay provided from June 18, 2020, through June 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from 
April 12, 2019, to October 13, 2019. 
 
You asked the Plan to waive the coinsurance for an oxygen concentrator. You say that you feel like you should 
not be charged for services provided in 2019. The Plan denied your request. The Plan says the claims were 
processed correctly, and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment and related supplies.  
 
You received an oxygen concentrator from April 12, 2019, to October 13, 2019 for a total of 7 services. The 
allowed amount per each visit is $97 and 20% of that is $19.40. The total amount you owe is: $19.40 
(coinsurance) x 7 (services) = $135.80. 
 
 
 
You have been asked to pay the total coinsurance amount of $135.80 for an oxygen concentrator. An oxygen 
concentrator falls within the durable medical equipment 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 an oxygen concentrator provided from April 12, 2019, to October 
13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 9, 
2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were discharged because the 
hospital was clearing out due to COVID-19 so you should not be responsible for the charges. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 
care 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 emergency care provided on 
March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says this procedure is considered experimental and Medicare does not provide coverage for 
interspinous spacer(s). 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show safety and efficacy. Open 
laminectomy is the gold standard. There is no instability. Hardware 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, 
including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardiac monitor evaluation (G2066) 
performed on July 9, 2020. 
 
You asked the Plan to waive the copayment for a cardiac monitor evaluation. You say that the specialist 
copayment of $40 should apply. The Plan denied your request. The Plan says the correct copayment 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 a $50 
copayment for all other (non-preventive) diagnostic procedures and tests.  
 
You have been asked to pay a $50 copayment for a cardiac monitor evaluation. A cardiac monitor evaluation 
falls 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 copayment for a cardiac monitor evaluation (G2066) performed on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on July 14, 2020, to July 16, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not think that you 
should have to pay for this. 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 $350 
copayment for outpatient surgery/outpatient hospital.  
 
You have been asked to pay a $350 copayment for an outpatient surgery. An outpatient surgery falls within the 
outpatient surgery/outpatient hospital 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 
an outpatient surgery provided by a participating provider on July 14, 2020, to July 16, 2020.