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

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650). 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that this service was medically necessary. 
The Plan denied your request. The Plan says there is no evidence that the prescribing physician ever had an 
exam with the enrollee. 
 
The Plan follows Medicare rules. Medicare rules say that the criteria in LCD L33790 must be met before 
coverage for spinal orthoses can be approved. 
 
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 the lumbar-sacral orthosis. Our reviewer 
says that the requested orthosis is not medically necessary and reasonable. Our physician reviewer found and 
appropriate history and a physical examination of the back would reasonably be required to adequately assess 
whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-
sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient 
documentation of a credible evaluation and a credible physical examination of the back. 
 
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 lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build up (D2950) for tooth #15 provided on July 20, 
2020. 
 
You asked the Plan to pay for the dental service. You say that you were advised that this service was not 
covered because it was a repeat procedure. You say that this was not a repeat. You say that it was for the 
cement build up that occurs after a root canal is performed. You also say that "core build up" is cement to 
strengthen the tooth. The Plan denied your request. The Plan says single tooth restorations are covered only 
after 60 months from the date of the initial placement. The Plan also says that the frequency limit has been 
exceeded. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of once every 60 
months has been exceeded. The record shows that the Plan paid for core build up that you received on June 12, 
2020. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) for tooth #15 
provided on July 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has reached a plateau in the program. 
 
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 the visits. 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 additional requested therapy is not generally accepted as specific and 
effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy 
of 15 outpatient visits and the records do not demonstrate that the unique skills of a professional therapist are 
required to safely and effectively provide treatment, that the services can be safely and effectively performed 
only by a therapist, or for physical therapy, by or under the supervision of a therapist. You have been instructed 
in and are compliant in a home exercise program. The requested services are not part of a maintenance 
program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design 
and/or deliver a program to maintain your 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the diagnostic testing services provided on 
October 22, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you should have been told the 
cost before the service. The Plan denied your request. The Plan says the copay 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 $100 
copay for diagnostic procedures in an outpatient hospital facility.  
 
You have been asked to pay a $100 copay for the services you received in an outpatient hospital facility. The 
services fall within the outpatient diagnostic tests 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 
copay for the diagnostic testing services provided on October 22, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit and services 
(99283, 93005) provided on October 16, 2020. 
 
You asked the Plan to waive the copayment for the emergency services. You say that you were in the 
emergency department for 7 hours and left without being seen. You also say that an electrocardiogram (EKG) 
was performed. The Plan denied your request. The Plan says emergency care (an EKG) was provided on the 
date in question. Emergency care is subject to a $120 copayment. 
 
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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for the emergency services. An EKG was provided while in the 
emergency department. 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 emergency room visit and 
services (99283, 93005) provided on October 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a home evaluation is required. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the therapy notes do not reveal that your functional level is significantly impaired enough to not 
complete MRADLs. The mobility deficit can be resolved with a walker. The documentation does not reveal a 
home evaluation indicating that the home is appropriate for a wheelchair or that the manual wheelchair will 
significantly improve your ability to participate in MRADLs in the home, or that the enrollee or caregiver can 
safely propel the requested wheelchair in the home. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight manual wheelchair.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the enrollees nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an 
IRF level of 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for discharge day management (99239) provided on June 17, 
2020. 
 
You asked the Plan to pay for discharge day management. You say that this is supported. The Plan denied your 
request. The Plan says only one discharge service can be billed per hospital stay. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, there is conflicting 
information in the submitted medical records on whether the enrollee was discharged on June 17, 2020, or June 
18, 2020. This service has also been previously billed and paid for June 18, 2020. Discharge day management 
cannot be billed more than once for a single hospital stay. Based on this information, we decided that Medicare 
rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does 
not have to pay for discharge day management (99239) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for podiatry services. You say that there are limited podiatrists in the area for number of patients needing care, and these services were medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 medical services provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on May 22, 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 claims were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 
21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue and the claims were not billed with the required POS code 21. 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 pay for the testing services rendered on May 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing.

You asked the Plan to pay for the CGP testing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the CGP testing have not been met. Therefore, we decided that the Plan does not have to pay for the Comprehensive Genomic Profile (CGP) testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genomic sequencing provided to the enrollee.

You asked the Plan to pay for this service. You say that this testing was medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records show the enrollee was diagnosed malignant neoplasm of connective and soft tissue, unspecified (poorly differentiated metastatic epithelioid malignant peripheral nerve sheath tumor). A request for genomic analysis for malignant neoplasm of connective tissue was made. The records do not show the enrollee has a clear indication for the genomic testing as a clear diagnosis has been made via pathology and no treatments have been proposed on the notes provided thus far.

Therefore, without sufficient support made for this request, the genomic testing will be considered not medically necessary based on the documentation provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for genomic sequencing provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two core buildups, including any pins when required 
(D2950 x2) provided on October 20, 2020. 
 
You asked the Plan to pay for the core buildups. You say that you feel that this service should be covered. The 
Plan denied your request. The Plan says this service is 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 two 
core buildups, including any pins when required (D2950 x2) provided on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided May 27, 2020 to May 
31, 2020. 
 
You asked the Plan to pay for the inpatient services. You say that all of your claims have been denied, so you 
are appealing. Please process the claim for payment. You have an authorization number for this enrollee. The 
Plan denied your request. The Plan says this is a duplicate of a previously processed claim. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, we find that CPT code this claim is a duplicate of another claim that was processed October 28, 
2020. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not 
been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided 
May 27, 2020 to May 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on 
September 25, 2020. 
 
You asked the Plan to pay for a shoulder-elbow-wrist-hand orthosis. You say that the requested item is 
medically necessary. The Plan denied your request. The Plan says rules for payment have 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 pay for a shoulder-elbow-wrist-hand orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the right 
shoulder.  
 
The documentation in the case file does not support that the requested shoulder/arm orthosis was medically 
reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably 
be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. 
The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee 
in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 

 
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 shoulder-elbow-wrist-hand orthosis have not been met. Therefore, we decided 
that the Plan does not have to pay for a shoulder-elbow-wrist-hand orthosis (L3960) provided on September 25, 
2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the hearing aids rendered on February 23, 2018. 
 
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 that hearing aids are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that hearing aids are not covered by Medicare; however, the 
Plan's Evidence of Coverage clearly states that there is a supplemental routine hearing aid benefit with a $1,000 
allowance for hearing aids every three years. The Plan has not provided any explanation or documentation to 
support that the routine benefit would not cover these services. Therefore, we decided that the Plan has to pay 
for the hearing aids rendered on February 23, 2018.  
 
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 pay for the durable medical equipment (L0651) provided on October 
27, 2020. 
 
You asked the Plan to pay for the durable medical equipment (L0651). You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. 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 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 the durable medical equipment (L0651) provided on October 27, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating provider on November 19, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you ended up needing to go 
to the emergency room the next day and you had to pay the emergency room copayment too. 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 $40 
copayment for urgently needed services.  
 
You have been asked to pay a $40 copayment for urgent care services. The correct copayment has been applied 
to the services that were provided. Urgent care services fall within the urgently needed services 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 urgent care services provided by a participating 
provider on November 19, 2020.