Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a front fixed bridge with crowns. 
 
You asked the Plan to pre-approve the fixed bridge. You say that you feel that this is necessary. The Plan 
denied your request. The Plan says the documentation does not indicate that you have a condition for which a 
fixed bridge can be covered under your policy. 
 
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 fixed 
bridge when the services are medically necessary and reasonable.  
 
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 fixed bridge. Our reviewer says that 
the requested fixed bridge is not considered reasonable and necessary in this case. Our physician reviewer 
found a review of the patient's dental record and radiographs indicate a maxillary fixed bridge in place which 
appears adequate. There were no indications of defects or any narrative as to why a replacement was needed. 
The documentation provided did not indicate any reason for the placement of a new fixed anterior bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the fixed bridge have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a front fixed bridge with crowns.
Appeal type: Supplemental Benefit
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will not pay for dental services. Dental services are items and services involving the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this rule in the SSA, Section 1862(a)(12) and Medicare Benefit Policy Manual, Chapter 15, Section 150.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan covers certain dental services as a supplemental (extra) benefit. The contract says that you are only covered for preventive dental benefits from an in or out-of-network provider. You can find this information on page 65 of the Plan's 2020 Evidence of Coverage (EOC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee from December 
28, 2019 and December 29, 2019. 
 
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 Original Medicare would be responsible for payment of all Medicare covered 
services related or unrelated to the enrollee's terminal condition. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 23, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services 
provided to the enrollee from December 28, 2019 and December 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 29, 2020 to 
February 7, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically 
necessary. The Plan denied your request. The Plan says that the enrollee could have been treated in another 
level of care. 
 
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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed 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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 29, 2020 to February 7, 2020.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic services provided on September 25, 
2019. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that you were told that you 
would have no cost sharing. The Plan denied your request. The Plan says that the copayment you are being 
charged is correct. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for Medicare-covered chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance for Medicare-covered chiropractic services. The Plan contract does not clearly say how much 
enrollees must pay for Medicare-covered chiropractic services. This means that the Plan did not follow 
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the 
coinsurance for chiropractic services provided on September 25, 2019.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring in the 
operating room, one on one monitoring requiring personal attendance, each 15 minutes (CPT Code 95940) 
provided on January 17, 2020. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
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 95940 is not supported in the medical record. The documentation submitted did not 
include documentation of Continuous intraoperative neurophysiology monitoring in the operating room, one on 
one monitoring requiring personal attendance, each 15 minutes; therefore, the billed service cannot be verified. 
Of note, the submitted medical records refer to full dictation which is not found. In addition, this procedure is 
not supported when performed by the surgeon or anesthesiologist. It is noted that multiple attempts were made 
to contact the provider for additional information. We have insufficient documentation to corroborate the 
services so we can confirm Medicare coverage has been met. 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 pay for continuous intraoperative neurophysiology monitoring in the operating room, one on one 
monitoring requiring personal attendance, each 15 minutes (CPT Code 95940) provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 units of neuropsychological testing. 
 
You asked the Plan to pre-approve 12 units of neuropsychological testing. You say that the requested 12 units 
of neuropsychological testing is medically necessary. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for 12 units of neuropsychological testing. 
 
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 12 units of neuropsychological testing. 
Our reviewer says that the enrollee does not meet criteria for 12 units of neuropsychological testing. Our 
physician reviewer found based on review of the records provided, this enrollee has had difficulty with 
depression and had used crack cocaine presenting with a long history. Documentation shows that there is no 
history of this enrollee having issues with seizure disorder, stroke, or multiple sclerosis justifying a need for 
this procedure. There is in the provider's letter a possible history of concussion although it is unclear when. The 
documentation presented showed the enrollee being oriented to time, place, person and was found to be alert 
with average intelligence. Documentation did not show any difficulties cognitively for this individual. The 
enrollees provider has asked for a diagnosis clarification for possible Attention Deficit Hyperactivity Disorder, 
Depression, Anxiety or Bipolar Disorder. Utilizing the criteria from LCD L34646 that this testing is intended to 
diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly 
on the brain including detection of neurologic disease based on quantitative assessment of neurocognitive 
abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive 
effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central 
nervous system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or 
management strategies among individuals with neuropsychiatric disorders, it does not appear that this enrollee 
meets the criteria therefore it does not appear medically necessary or reasonable to have neuropsychological 
testing as outlined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 units of neuropsychological testing have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 12 units of neuropsychological testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lift chair purchased on August 6, 2019 from a non-
Medicare provider. 
 
You asked the Plan to pay for the lift chair. You say that this was prescribed by your doctor and per your 
conversation with a Plan representative your doctor completed the form showing medical necessity. The Plan 
denied your request. The Plan says this provider is not certified with Medicare. The Plan states they have no 
evidence on file that you called the Plan prior to purchase of the seat lift and there are no calls on file from the 
provider prior to you obtaining the seat lift, and no prior authorizations. 
 
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. 
 
Review of the file show that you purchased the lift chair from a non-Medicare provider on August 6, 2019. The 
rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of 
an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must 
be enrolled in the Medicare program. 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 lift chair purchased on 
August 6, 2019 from a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seating system (E1007). 
 
You asked the Plan to pre-approve a power seating system. You say that the enrollee needs this to prevent 
pressure ulcers. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power seating systems are covered only when the 
beneficiary has one of the indications listed 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 a power seating system. Our reviewer 
says that the requested power seating system is not medically necessary.  
 
 
Our physician reviewer found there is no documentation that the beneficiary is at high risk for development of 
a pressure ulcer and is unable to perform a functional weight shift; or the beneficiary utilizes intermittent 
catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 
the power seating system is needed to manage increased tone or spasticity. The tilt feature alone will meet the 
enrollee's needs for positioning with regard to reducing the risk of a pressure ulcer. 
 
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 power seating system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seating system (E1007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics (L3000). You say that you would like the Plan to reconsider 
their denial. 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 (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Over Bed Table. 
 
You asked the Plan to pre-approve an Over Bed Table (E0274). You say that the enrollee has a history of 
frequent falls. The Plan denied your request. The Plan says an Over Bed Table is not used to treat a medical 
condition. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item 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 an Over Bed Table.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) to be provided at 
the in-network benefit level by an out-of-network provider. 
 
You asked the Plan to pre-approve MRI. You say that this provider is the only facility that has the equipment 
and software to perform this testing. The Plan denied your request. The Plan says the denial of authorization for 
coverage at the in-network benefit level is correct, because this provider is out-of-network with the Plan and 
you can be treated by an in-network provider. 
 
Medicare rules say that plans can establish a network of providers for services. 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 $310 copayment for each in-
network MRI or 50% coinsurance for each out-of-network MRI. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services at the in-network benefit level. You may choose to receive service 
from this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-
approve Magnetic Resonance Imaging (MRI) to be provided at the in-network benefit level by an out-of-
network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation supports the 
request for an LTACH admission. The Plan denied your request. The Plan says the necessary care can be 
provided at the skilled nursing facility. 
 
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. Our 
physician reviewer found that there is no evidence that the enrollee requires services that are not currently 
available. Our reviewer says that the enrollee can remain at the current acute care hospital until no acute 
services are required.  
 
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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana (J7605).

You asked the Plan to pre-approve Brovana. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Brovana. Our reviewer says that the criteria for coverage of Brovana have not been met. Our physician reviewer found the Plan requires a trial of Perforomist (formoterol) before they will approve the requested drug. Based on the medical records provided, you have not tried and failed the required drug and there is no indication that the  required drug would likely be less effective or have adverse effects for you.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (J7605).
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for acute rehab admission. 
 
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. You 
do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen 
hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a 
lower level of care. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.