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

 
We decided that the Plan has to pre-approve a myoelectric upper limb orthosis (L8702). 
 
You asked the Plan to pre-approve the myoelectric upper limb orthosis. You say that the orthosis is medically 
necessary. The Plan denied your request. The Plan says that this device is considered investigational for the 
enrollee's condition. 
 
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 myoelectric upper limb orthosis. 
Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our 
physician reviewer found that after review of the current medical literature on myoelectric upper limb orthoses, 
it is medically acceptable to utilize this type of orthosis in this young patient to attempt to provide some 
dominant hand functionality. The literature demonstrates clinically important motor control gains in individuals 
who have tried these types of orthoses. 
 
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 myoelectric upper limb orthosis have been met. Therefore, we decided that 
the Plan has to pre-approve a myoelectric upper limb orthosis (L8702).  
 
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 pre-approve the CardioMEMS device (CPT Codes: C2624 and 
33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the device is not necessary. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device (CPT Codes: C2624 and 33289).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on January 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 5, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 5, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are 
medically necessary. The Plan denied your request. The Plan says that you can be treated in a lower level of 
care, such as outpatient treatment. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric hospital services. 
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary in this 
case. It is not expected you would improve in a reasonable period of time as you do not have suicidal or 
homicidal ideation noted and no auditory or visual hallucinations. You do not have dangerousness to self or 
others and were compliant with your treatment. Our physician reviewer found that your condition does not 
meet Medicare criteria for inpatient psychiatric hospital services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Watchman Procedure including any associated 
procedures and hospital inpatient admission (CPT Codes: 33340, 93355). 
 
You asked the Plan to pre-approve the services. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the requested hospital stay isn't covered because it's associated with a procedure 
that isn't covered. 
 
The Plan must follow Medicare rules. 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 
services. Our reviewer says that the documentation does not support that the criteria for inpatient payment are 
met in this case. Our physician reviewer found the records did not show that at the time of admission there was 
an expectation for this patient to require more than two midnights of inpatient services. The medical records do 
not meet the LCD Medicare coverage criteria. The Watchman implant procedure is not on the inpatient only 
list. 
 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Watchman Procedure including any associated procedures and hospital inpatient 
admission (CPT Codes: 33340, 93355).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you need a second opinion where they offer 
clinical trials. The Plan denied your request. The Plan says you can get the care you need within the plan 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
oncology services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at a SNF on January 10 to February 
28, 2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that a representative of the SNF told 
you there would be no cost or copayment for your stay for up to 90 days. 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 each day of days 21-100 of a stay at a SNF.  
 
You have been asked to pay a $50 copayment for a stay at a SNF. A stay at a SNF falls within the "Skilled 
nursing facility (SNF) 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 a stay at a 
SNF on January 10 to February 28, 2020.  
 
Your complaint about receiving erroneous or ambiguous information from a representative of the SNF 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's 
conditions have been well-controlled at home. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital for a stroke. He was transferred to acute inpatient 
rehabilitation and then discharged to home. His medical problems are stable. The complexity of the enrollee's 
nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that he will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair (K0823). 
 
You asked the Plan to pre-approve the power wheelchair. You say that you need a power wheelchair and you 
disagree with the modification to a walker. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria for a power wheelchair. The plan has instead approved a four wheeled walker with a 
seat (E0143). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the documentation supports that the member is able to use a walker to 
resolve any mobility limitations in the home and is also able to self-propel a manual wheelchair for any longer 
distances.  The requested DME is not 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 the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 power wheelchair (K0823).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to the full allowed amount for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on June 18, 2020. 
 
You asked the Plan to the full allowed amount for the dental services. You say that you understand the provider 
payments are reduced to what is reasonable including the copayment. You say that not even paying the 
reasonable allowable amount is unethical. You also say that you should be reimbursed $40 to correct this error. 
The Plan denied your request. The Plan says all dental visits are subject to a $40 copayment. The Plan says that 
services are paid according to a maximum allowable charge (MAC). The Plan also says that the MAC would 
include any copayment or coinsurance allowed amount. 
 
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, all dental visits are subject to a $40 
copayment. 
 
CPT Code Billed Amount Allowed Amount Plan Paid Copayment Your Responsibility 
D0120 $37 $21 $21 $0 $16 
D1110 $105 $46 $6 $40 $99 
TOTAL:   $27  $115 
 
 
 
The maximum allowable charge (MAC) includes any copayment or coinsurance allowed amount. Therefore, 
we decided that the Plan does not have to the full allowed amount for the periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (80061, 85025, 84443) provided. 
 
You asked the Plan to pay for the lab services. You say that the testing should be covered. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The testing (CPT 80061, CPT 85025) at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this testing solely for screening purposes. 
 
The rules also say that cardiovascular disease screening (CPT 84443) is covered once every 60 months. 
Additionally, you were informed that these services would not be covered, and signed a consent form prior to 
receiving them.  
 
 
 
Therefore, we decided that the Plan does not have to pay for the lab services (80061, 85025, 84443) provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 2, 2020 and 
billed under code 80307. 
 
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 place of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified.   
 
  
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 cannot be paid as billed due to 
a discrepancy with the POS code. Therefore, we decided that the Plan does not have to pay for lab services 
provided to the enrollee on June 2, 2020 and billed under code 80307.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services rendered on May 2, 2020 to 
May 29, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare only pays for specific outpatient services 
while an enrollee is under inpatient status. 
 
 
 
We looked at the file and Medicare rules. The file shows that the provider billed outpatient services while the 
enrollee was registered as an inpatient. The services were not those covered by Medicare while the enrollee is 
inpatient. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services rendered 
on May 2, 2020 to May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on May 29, 2020.You asked the Plan to pay forthe additional intraoral periapical x-ray. You say that you were told that your plan covers x-rays and cleanings.The Plan denied your request. The Plan says intraoral x-rays benefit has been exhausted.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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on May 29, 2020, which was covered by the Plan, and your intraoral x-rays benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe additional intraoral periapical x-ray provided on May 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound of the breast (76641) provided December 6, 2019.You asked the Plan to pay forthe ultrasound. You say that the services were medically necessary.The Plan denied your request. The Plan says the record does not support the 2 units billed.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 2 units of CPT code 76641 are not supported in the medical record. The medical record only supports 1 unit of CPT code 76641. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met.Therefore, we decided that the Plan does not have to pay foran ultrasound of the breast (76641) provided December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided to the enrollee on 
January 31, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the 
specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the 
records reflect of place of service of a doctor's office (POS 11) Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for molecular pathology services provided to the enrollee on January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for periodontal scaling and root planing provided on May 13, 2020. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you were referred for the 
cleaning due to the buildup and bone loss of your teeth. You say that your dental bill should be covered. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers periodontal 
scaling and root planing 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 pay for periodontal scaling and root planing. Our 
reviewer says that the criteria for coverage have been met. Our physician reviewer found that you have 
abnormal periodontal pockets in the four quadrants (4-7mm) and there is evidence of bone loss. Our reviewer 
says that periodontal scaling and root planing in four quadrants is reasonable and necessary. 
 
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 periodontal scaling and root planing have been met. Therefore, we decided that 
the Plan has to pay for periodontal scaling and root planing provided on May 13, 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: Unfavorable

 
We decided that the Plan does not have to pay for the telehealth services rendered on May 26, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the correct POS code. 
 
We looked at the file and Medicare rules. The file shows that the telehealth services were not billed with the 
correct place of service code. Therefore, we decided that the Plan does not have to pay for the telehealth 
services rendered on May 26, 2020.