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

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the device is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
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 the ventilator. Our reviewer says that 
the requested respiratory assist device is not medically necessary. Our physician reviewer found the requested 
Life2000 device is not a true ventilator. It is designed to provide positive airway pressure during activity. It 
does not have the full functionality of a ventilator. There is insufficient evidence to support its effectiveness in 
any respiratory condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services with CPT code S9328 
provided on May 26, 2020. 
 
You asked the Plan to pay for CPT code S9328. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the home infusion therapy services with CPT code S9328 provided on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the physician provided medically necessary services in good faith.The Plan denied your request. The Plan says the enrollee's plan requires authorization of network providers, and authorization for certain 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these OON services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says the notes provided by the doctor do not show the pain is from arthritis in the spine joints. 
 
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 block. Our reviewer says that the 
requested block is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is evidence of radiculopathy. The review has determined that the pain is not associated with the 
facet joint and has a radicular component. 
 
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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a lumbar/sacral facet joint block for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not allowed more than once every five years. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dentures 
once every five years.  
 
Dentures have been received within the past five years. Based on this information, we decided that the Plan's 
rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-
approve a complete maxillary denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is felt that the enrollee would benefit from an 
intensive therapy program. The Plan denied your request. The Plan says criteria for IRF care are not met. 
 
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 treatment of an infection of prosthetic hip. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for CT scans of the thorax and abdomen 
provided on August 25, 2020. 
 
You asked the Plan to waive the copayments for CT scans of the thorax and abdomen. You say that you feel 
that the scans should only count as one because you only had one IV and were only in the tube once. 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 $155 
copayment for each CT scan.  
 
You received a CT scan of the thorax on August 25, 2020. Therefore, you are responsible to pay the $155 
copayment.  
 
You received a CT scan of the abdomen on August 25, 2020. Therefore, you are responsible to pay the $155 
copayment. 
 
The total amount you owe is: $310.  
 
You have been asked to pay the total copayment amount of $310 for CT scans of the thorax and abdomen. CT 
scans of the thorax and abdomen 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 copayments for CT scans of the thorax and 
abdomen provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan 
denied your request. The Plan says the benefit has been exhausted. 
 
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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 6 one-way 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient care provided on July 31, 2020. 
 
You asked the Plan to pay for the initial hospital inpatient care. The Plan denied your request. The Plan says 
when you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B 
services related to your terminal prognosis are paid for by Original Medicare, not the Plan. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The file shows that you were under the Medicare hospice benefit for the dates of service at issue in this appeal. 
Therefore, we decided that the Plan does not have to pay for initial hospital inpatient care provided on July 31, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need the foot orthotics to compensate for 
your condition. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from April 15, 
2020 to June 13, 2020  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim for date of service April 15, 2020 through June 13, 2020 is a 59-day episode of 
care. Per Medicare guidelines plan of care are paid based on a 60-day episode of care (before January 1, 2020) 
or a 30-day period of care (on or after January 1, 2020). Therefore, per the guidelines we find that the Medicare 
rule for payment of this claim has not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed based on the amount of days billed. Medicare rules for coverage of this service have not been met. 
Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from 
April 15, 2020 to June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Shingles vaccine provided on August 27, 2020. 
 
You asked the Plan to pay for the shingles shot. You say that you were told it would be covered. The Plan 
denied your request. The Plan says this is not a covered Part B service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles shot. 
The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the shingles 
shot. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on August 27, 
2020.  
 
Benefits for the shingles shot 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 forout of network physician services provided to the enrollee on August 25, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forout of network physician services provided to the enrollee on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat radiofrequency ablation. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint radiofrequency neurotomy is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of bilateral axial lumbar back pain radiating to his buttock and 
lower extremity. Repeat denervation procedures at the same level can be considered reasonable and necessary 
with appropriate documentation in the medical record of return of pain and loss of function. However, repeat 
RFA involving the same joint will only be covered if the enrollee experienced greater than or equal to 50% 
improvement in pain and specific mobility-related activities of daily living that lasted for at least 6 months. In 
this case, the records show that the previous injection did not provide at least 50% pain relief for 6 months. 
Therefore, the requested service is not medically reasonable or necessary to treat the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a repeat radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
accessories (E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and accessories. You say that this is 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
 
 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and accessories (E0667).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an apicoectomy and retrograde filling. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 an 
apicoectomy and retrograde filling.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient hospital services provided on
August 15, 2017.
You asked the Plan to waive the deductible for outpatient hospital services. You say that you disagree with
charges from 2017 and feel that the Plan made a mistake. 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. Your
contract with the Plan says that there is a $750 deductible for out-of-network outpatient hospital services.
You received outpatient hospital services from an out-of-network provider on August 15, 2017. The record
shows that you had only paid $103.49, which is less than the $750 deductible. Therefore, you are responsible to
pay the total allowed amount of $84.69.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible for out-of-network outpatient hospital services. This cost sharing is a contractual obligation that had
not been met at the time outpatient hospital services was received on August 15, 2017. Therefore, we decided
that the Plan does not have to waive the deductible for outpatient hospital services provided on August 15,
2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye exam provided on August 28, 2020. 
 
You asked the Plan to waive the deductible for the eye exam. You say that glaucoma and macular degeneration 
are necessary diseases to check for. You say that there is no cost for a yearly vision exam. The Plan denied 
your request. The Plan says the deductible applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that your combined deductible is $500. This is the amount you have to pay out-of-
pocket before we will pay our share for your covered medical services. Until you have paid the combined 
deductible amount, you must pay the full cost for most of your covered services. 
 
The item or service you asked the Plan to waive the deductible for falls within the "Vision services (Medicare-
covered)" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your 
$500 deductible applies to vision services. The records show that a medical eye exam was also provided. 
 
This cost sharing is a contractual obligation that had not been met at the time the eye exam was received on 
August 28, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the eye exam 
provided on August 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot x-ray provided on July 9, 2020. 
 
You asked the Plan to waive the copayment for the foot x-ray. You say that you were informed you were 
charged a $40 copayment in error. The Plan denied your request. The Plan says the claim reprocessed to fully 
pay for the office visit and only apply a $20 copayment for the x-ray.  
 
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 
copayment per visit for laboratory tests, non-radiological diagnostic tests, flat film x-rays, and ultrasounds. 
 
You have been asked to pay a $20 copayment for the foot x-ray. The foot x-ray 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 the foot x-ray provided on July 9, 2020.