Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on May 27, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you do not agree with these 
charges. 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 $20 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay $10.36 which is less than your copayment amount of $20 for specialist services. 
Specialist services fall within the physician/practitioner services/specialist benefit category. The correct 
copayment has been applied to the services that were provided. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for specialist services provided by a participating provider on May 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed and a table to go over the 
bed. 
 
You asked the Plan to pre-approve the total electric hospital bed and the table. You say that the enrollee 
requires the items in dispute because he is vent dependent and totally bed bound. You say that the enrollee 
needs to breath and be repositioned every two hours due to an ulcer. You say that the enrollee also has brain 
damage. The Plan denied your request. The Plan says the items in dispute are not covered benefits. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 
Medicare rules also say that for equipment to be covered, it must primarily serve a medical purpose. 
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. The over-the-bed table at issue in this appeal does not serve a purpose that is primarily 
medical in nature. This item is available to the general public and would be helpful even to those who are not 
sick or injured. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed 
and a table to go over the bed.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of the knee meniscus (knee meniscectomy) 
with transplant. 
 
You asked the Plan to pre-approve these services. You say that you need the surgery. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a knee meniscectomy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have complaints of progressively worsening left knee pain.  
 
No current mechanical symptoms are documented. The clinical exam findings document a limited range of 
motion, weakness, and a painful McMurray's test. You are diagnosed with a possible medial meniscus tear of 
the left knee. The Medicare rules do not cover the requested procedure in the absence of mechanical symptoms 
or positive McMurray's test (a thud or click along with the pain). The services are not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve removal of the knee meniscus (knee meniscectomy) with transplant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a T7 kyphoplasty.
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 medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a kyphoplasty is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee presents with a history of chronic back pain and multiple thoracic compression fractures. She had prior kyphoplasties at T11 and T12. She has a known chronic T7 compression fracture with 50 percent height loss anteriorly. She has reported increased pain in the T7 region since the recent T11 kyphoplasty procedure.
There is no current imaging to support a current acute or subacute compression fracture at T7. She has failed conservative treatment, including activity modification, medications, bracing, and home exercise program. She does not meet the criteria for coverage and the requested kyphoplasty is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a T7 kyphoplasty.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a joint survey provided on February 28, 2020.
You asked the Plan to waive the copayment for a joint survey. You say that you disagree with 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 $180 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $107.12, which is less than the $180 copayment for a joint survey. A joint survey 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 joint survey provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visits (99345, 99350) provided by a provider that has 
opted out of the Medicare program from January 31, 2020 to February 17, 2020. 
 
You asked the Plan to pay for home visits. You say that you were told these services would be covered. The 
Plan denied your request. The Plan says the provider of these services has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
home visits (99345, 99350) provided by a provider that has opted out of the Medicare program from January 
31, 2020 to February 17, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional units of CPT codes 37243 and 75726 provided on 
September 30, 2019. 
 
You asked the Plan to pay for the additional units. The Plan denied your request. The Plan says only one unit of 
these services is supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that the additional units of CPT code 37243 and 75726 are not supported in the medical record. The 
medical record only supports one unit of CPT code 37243 and 75726. Based on this information, we decided 
that Medicare rules for coverage of the additional units have not been met. Therefore, we decided that the Plan 
does not have to pay for additional units of CPT codes 37243 and 75726 provided on September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you wanted your friend 
to transport you to the hospital. The Plan denied your request. The Plan says that the cost share 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 $250 
copayment for each one-way Medicare-covered ground trip.  
 
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls 
within the one-way Medicare-covered ground trip 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 ambulance transport provided on March 18, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a completion thyroidectomy for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that the nodule is getting larger. The Plan denied 
your request. The Plan says that there is no documentation of malignant cells found with fine-needle aspiration 
biopsy, documentation of compressive symptoms, or documentation showing change in thyroid nodule size. 
 
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 procedure. Our reviewer says that 
the requested procedure is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is a 65-year-old female, with a history of cancer who is being considered for an elective 
right thyroid lobectomy for an enlarged nodule. The nodule has been biopsied and came back as benign, 
Bethesda 2. This nodule is 3.7cm in its largest dimension. The criteria for elective thyroid surgery is not clear 
cut. A nodule that is above 4cm should be removed. However, a nodule that is smaller than 4cm can also be 
considered for removal. Nodules that are 3-4cm can be removed if it causes symptoms. The enrollee can feel 
the mass and it is easily visualized and palpated in the neck. Another concern is that the FNA is a false negative 
given the size of the nodule. In addition, the patient has a history of cancer and received radiation which puts 
her at a higher risk category. It is not the standard of care to state that all benign nodules less than 4cm should 
not be removed. This is a decision that should be made by the surgeon. In this case, the surgeon discussed 
surgical options with the enrollee who wanted to proceed. It is both reasonable and necessary to proceed with 
surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the procedure have been met. Therefore, we decided that the Plan has to pre-
approve a completion thyroidectomy 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6545, 
A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are required item. 
The Plan denied your request. The Plan says the compression stockings are not a reusable supply item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6545, 
A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6545, A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says stasis ulcers are not a covered benefit. 
 
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 therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee appears to have a venous stasis ulcer and chronic peripheral vascular disease, not acute. This 
clinical presentation does not qualify for HBO therapy based on the coverage rules. 
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 therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen therapy for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy. 
 
You asked the Plan to pre-approve physical therapy. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for additional physical therapy is correct, because it is unclear 
if the enrollee has improved with recent therapy, but it does not appear so. 
 
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the requested therapy is not generally accepted as specific and 
effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition.  
 
The documentation does not show that the enrollee requires ongoing unique skills of a professional therapist to 
safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a 
therapist or under the supervision of a therapist. The requested services are not part of a maintenance program 
and the specialized skill, knowledge, and judgment of a qualified therapist is not required to establish, design, 
and/or deliver a program to maintain the enrollee's 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 physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 20, 2020 
to February 28, 2020. 
 
You asked the Plan to waive the coinsurance for dialysis. You say that you cannot afford 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 20% 
coinsurance for renal dialysis for services to treat kidney disease.  
 
You received dialysis from January 20, 2020 to February 28, 2020 for a total of 16 visits. The total allowed 
amount is $4,800 and 20% of that is $960.  
 
You have been asked to pay the total coinsurance amount of $960 for renal dialysis for dialysis. Dialysis falls 
within the services to treat kidney disease 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 dialysis provided from January 20, 2020 to February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), extraction (D7210), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on April 13, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, extraction, and deep sedation/general anesthesia. You say that you had to receive these services from an oral surgeon due to the closures of dentist offices. The Plan denied your request. The Plan says you did not elect to purchase an optional supplemental benefit plan. The Plan also says that these 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 pay for the problem focused limited oral evaluation (D0140), extraction (D7210), and each subsequent 15 minute increment of deep sedation/general anesthesia (D9223) provided on April 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).

You asked the Plan to pre-approve IGRT. The Plan denied your request. The Plan says there is no soft tissue mass, and no prior radiation to the area.

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 IGRT. Our physician reviewer found that IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and thus allow reduction in the volume of normal tissues exposed to radiation.  For radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary to escalate the dose, particularly when using very high dose per fraction, or when critical normal tissues abutting the target necessitate daily image guidance to allow minimal planning margins to spare the normal tissue. In this case, the intent is clearly palliative, in an enrollee with widespread disease. There is no plausible rationale for what benefit IGRT would afford. The records describing the need for IGRT are from a template/boilerplate form and do not describe specific need for this enrollee. Therefore, the requested services are not medically reasonable or 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 IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve Image Guided Radiation Therapy (IGRT).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ondansetron provided on April 19, 2020. 
 
You asked the Plan to pay for the Ondansetron. You say that this medication was medically necessary. The 
Plan denied your request. The Plan says Ondansetron is a self-administered drug, and not covered by Medicare 
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 pay for the Ondansetron provided on 
April 19, 2020.  
 
Benefits for the Ondansetron 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low dose computed tomography (LDCT) services. 
 
You asked the Plan to pre-approve the LDCT. You say that your family history and exposure to second hand 
smoke should be considered. You say that approval of this cancer screening could save money and suffering in 
the future. The Plan denied your request. The Plan says the enrollee is a non-smoker and does not meet the 
criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary. Medicare rules say that LDCT scans are covered for certain 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 LDCT. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has an extensive history of 
second hand smoke exposure, no smoking history and no family history of smoking. Second hand smoke 
exposure is not a covered indication for LDCTs. 
 
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 LDCT have not been met. Therefore, we decided that the Plan does not have 
to pre-approve low dose computed tomography (LDCT) services.