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

 
We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose 
monitoring (A9276) and transmitters, external for use with interstitial continuous glucose monitoring (A9277). 
 
You asked the Plan to pre-approve the sensors and transmitters. You say that these are medically necessary. 
The Plan denied your request. The Plan says that the Guardian CGM does not meet the Medicare definition of 
durable medical equipment and is therefore not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies 
used with a non-therapeutic CGM. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting 
supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and 
supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial 
continuous glucose monitoring (A9276) and transmitters, external for use with interstitial continuous glucose 
monitoring (A9277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 19, 2019.You asked the Plan to pay forthe medical services. You say that there was no payment on the claim and youwould like the claim to be reprocessed and paid.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the medical services was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 19, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided from April 14, 2020 to April 16, 2020.You asked the Plan to pay forthe inpatient hospital care. You say that you should not be responsible for these charges.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $393 copay for each day for days 1-5 of inpatient hospital care. You have been asked to pay a $786 copay for the inpatient hospital care. The inpatient hospital care falls within the days 1-5 of inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided from April 14,2020 to April 16, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transfer to SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot keep your balance or function alone. 
You state you cannot stay alone at home without additional rehabilitation. The Plan denied your request. The 
Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found you have stabilized medically and have been receiving skilled rehab services in an inpatient 
rehabilitation facility (IRF). You continue to require skilled nursing and/or skilled therapy services on a daily 
basis. Although you are making slow progress with therapy, there is no indication that transfer to a SNF is 
required. You can continue to received skilled rehab services at the current IRF. There are no services offered 
at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab services 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 SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve transfer to SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intravitreal injection provided on 
September 16, 2020. 
 
You asked the Plan to waive the copayment for an intravitreal injection. You say that you disagree with the 
increase in 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 $400 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay the allowed amount of $304.97, which is less than the $400 copayment for an 
intravitreal injection. An intravitreal injection falls within the outpatient surgery, including services provided at 
hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an intravitreal injection provided on September 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT Code(s): 81298, 81406, 81408, 81321, 81403, 81407, 81404, 81162, 81295, 81405, 81292, 81201, 81479 and 81317) provided on July 24, 2020.
You asked the Plan to pay for the genetic testing. You say that the enrollee is newly diagnosed with prostate cancer; genetic testing was done and will return in two to three weeks for another consultation regarding the method of treatment. The Plan denied your request. The Plan says the records did not show that the enrollee
displays clinical features of the associated disease and the clinical information also did not show that the enrollee has close blood relatives with a history of cancer.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. LCD L36715 does not apply to this case. Furthermore, the provider has not given us sufficient evidence that verify the services were medically necessary. Therefore, we decided that the Plan does not have to pay for the genetic testing (CPT Code(s): 81298, 81406, 81408, 81321, 81403, 81407, 81404, 81162, 81295, 81405, 81292, 81201, 81479 and 81317) provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on September 28, 2020.You asked the Plan to pay forthe dental services. You say that you were going for your annual dental visit and you were not informed dental coverage was dropped from 2020.The Plan denied your request. The Plan says you did not elect to purchase any optional supplemental benefits and therefore did not have dental coverage for the 2020 benefit year.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental services provided on September 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, 
and preventive procedure provided on August 20, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, prophylaxis, and preventive 
procedure. You say that you were not advised that this provider was OON with your plan. The Plan denied 
your request. The Plan says these services were rendered by an OON provider. The Plan also says that no 
benefits are available for procedures performed by OON providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation, bitewing x-rays, prophylaxis, and preventive procedure provided on August 20, 2020 by an 
OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated knee orthosis with an adjustable 
flexion and extension joint (L1846). 
 
You asked the Plan to pre-approve a custom fabricated knee orthosis with an adjustable flexion and extension 
joint (L1846). You say that the requested custom fabricated knee orthosis with an adjustable flexion and 
extension joint (L1846) is medically necessary. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested custom fabricated knee orthosis with an adjustable flexion and extension 
joint (L1846). 
 
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 a custom fabricated knee orthosis with 
an adjustable flexion and extension joint (L1846). Our reviewer says that the enrollee does not meet criteria for 
the requested custom fabricated knee orthosis with an adjustable flexion and extension joint (L1846). Our 
physician reviewer found an L1846 custom fabricated orthosis is not medically necessary as there is no 
objective physical exam findings of characteristics which requires the use of a custom fabricated orthosis 
instead of a prefabricated orthosis such as a deformity of the leg or knee, size of the thigh and calf, and minimal 
muscle mass which to suspend an orthosis. 
 
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 custom fabricated knee orthosis with an adjustable flexion and extension joint 
(L1846) have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom 
fabricated knee orthosis with an adjustable flexion and extension joint (L1846).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA nerve ablation for genicular nerve block.
You asked the Plan to pre-approve RFA nerve ablation for genicular nerve block. You say that the requested
RFA nerve ablation for genicular nerve block is medically necessary. The Plan denied your request. The Plan
says the requested RFA nerve ablation for genicular nerve block is not medically 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 RFA nerve ablation for genicular nerve
block. Our reviewer says that the requested RFA nerve ablation for genicular nerve block is not medically
necessary. Our physician reviewer found the requested genicular nerve ablation of the knee is not reasonable
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed
body member. Currently there are no higher quality studies demonstrating long-term efficacy and there are
possible adverse effects associated with this procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of RFA nerve ablation for genicular nerve block have not been met. Therefore, we
decided that the Plan does not have to pre-approve RFA nerve ablation for genicular nerve block.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co payments for an office visit and ultrasound received.

You asked the Plan to waive the copayments for the services. You say that you have not had copayments before.The Plan denied your request. The Plan says the copayments were applied correctly according to the benefits and services rendered.

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 $15 copayment for specialist office visits and a $75 co payment for ultrasounds, for a total of $90.

You have been asked to pay a $90 total copayment for the services. This co payment is correct based on the plan language. 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 an office visit and ultrasound received.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound care services (11042 and 97597) provided from February 5, 2020 to April 22, 2020.You asked the Plan to waive the copayments forwound care services. You say that you should not have these copay charges.The Plan denied your request. The Plan says there is a $270 copayment for surgery or other services provided to you at an outpatient hospital setting.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 mustpay a $270 copayment for surgery or other services provided at an outpatient hospital. You have been asked to pay a $270 copayment or less for each session of wound care services. Wound care services fall within the surgery or other services provided atan outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forwound care services (11042 and 97597) provided from February 5, 2020 to April 22, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveseptoplasty and inferior nasal turbinate reduction.You asked the Plan to pre-approveseptoplastyand inferior nasal turbinate reduction. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 septoplasty and inferior nasal turbinate reduction. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given the computed tomography (CT) findings of mild generalized turbinate enlargement with a midline nasal septum, the proposed Septoplasty and Inferior Nasal Turbinate Reduction is not medically reasonable and 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 septoplasty and inferior nasal turbinate reduction have not been met.Therefore, we decided that the Plan does not have to pre-approveseptoplasty and inferior nasal turbinatereduction.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visit and diagnostic services 
rendered on September 16, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were 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 $30 
copayment per visit to a specialist and a $25 copayment for a carotid or peripheral vascular ultrasound. 
 
Review of the file shows that you received specialist services on September 16, 2020. You have been asked to 
pay a $30 copayment for these services. These services fall within the visit to a specialist benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan.  
 
The file shows that you received a vascular ultrasound on September 16, 2020. You have been asked to pay a 
$25 copayment for these services. These services fall within the carotid or peripheral vascular ultrasound 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. 
 
The total amount you have been asked to pay for these services is $55. 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 the office visit and diagnostic services rendered on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora standard wheelchair (K0001) that was provided on August 28, 2020.You asked the Plan to waive the coinsurance fora standard wheelchair. You say that due to the fact the wheelchair could not be used, there should be no coinsurance charged.The Plan denied your request. The Plan says that no additional charges were made for the replacement, therefore, the Plan 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 20% coinsurance for Durable medical equipment (DME)and related supplies. The item or service you asked the Plan to waive the coinsurance for falls within the Durable medical equipment (DME) and related suppliesbenefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is 20% coinsurance for Durable medical equipment(DME) and related supplies. This cost sharing is a contractual obligation that had not been met at the time a standard wheelchair was received on August 28, 2020.Therefore, we decided that the Plan does not have to waive the coinsurance fora standard wheelchair (K0001) that was provided on August 28, 2020.Your complaint about the standard wheelchair not being picked up in a sufficient amount of time, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 20mg tablets. 
 
You asked the Plan to pre-approve Prednisone. You say that Prednisone is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone 20mg tablets.  
 
Benefits for Prednisone 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrators purchased on July 29, 2020.
You asked the Plan to pay for the oxygen concentrators. You say that this should be covered because it will save yourself and the Plan money. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the oxygen concentrators purchased on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a prosthetic sock (L8470) provided April 27, 2020.
You asked the Plan to pay for the prosthetic sock. You say that the item was medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The itemized shipping receipt does not show delivery of L8470. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a prosthetic sock (L8470) provided April 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epifix.
You asked the Plan to pre-approve Epifix. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 Epifix. 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 request does not meet the coverage criteria as the member has wounds from squamous cell cancer, not diabetic foot ulcers or venous stasis ulcers. The review has determined that the requested Epifix is 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 Epifix have not been met. Therefore, we decided that the Plan does not have to pre-approve Epifix.