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

 
We decided that the Plan does not have to pre-approve core buildup for tooth #14 (D2950). 
 
You asked the Plan to pre-approve core buildup for tooth #14. You say that the service is necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
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 pre-approve core 
buildup for tooth #14 (D2950).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a visual field examination provided on 
August 6, 2020. 
 
You asked the Plan to waive the copayment for the visual field examination. You say that in the past your 
vision test and medical eye exam were performed during the same appointment and took one copayment. You 
say that the office advised you that they must split your appointments due to COVID-19 waiting room capacity 
limitations so the test could not be performed during one visit, which resulted in two copayments for the two 
separate dates of service. The Plan denied your request. The Plan says the copayments that applied to these 
dates of service have also been verified, as the tests were rendered on two separate dates of service. Your 
contract states that you have a $45 copayment for each medical vision service rendered by a specialist.  
 
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 $45 
copayment for Vision Care, Medical Eye Exam.  
 
You have been asked to pay $45 copayment for the visual field examination. The visual field examination falls 
within the Vision Care, Medical Eye Exam 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 visual field examination provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-covered chiropractic services provided from March 
17, 2020 to August 31, 2020. 
 
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these services are not covered 
when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the non-covered chiropractic services provided from March 17, 2020 to 
August 31, 2020.
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says you do not meet Medicare criteria for coverage of IRF 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 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. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. 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 the patient does not require skilled nursing services with the specialized skill, knowledge and judgment 
of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable 
treatment in a SNF. The patient does not have complex wound care, require breathing treatments, IV antibiotic 
or other ongoing SNF level SN need. The patient is asymptomatic. Vital sign measurements do not require 
skilled nursing services in a SNF. The patient does not require skilled therapy services with the specialized 
skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary 
and reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a 
combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require 
the necessary services on an inpatient basis, in a SNF setting. 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 SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor 
(CGM)(K0554, K0553). 
 
You asked the Plan to preapprove the CGM. You say that the DME is required for the enrollee's diabetes. The 
Plan denied your request. The Plan says review of the member records determine that the member doesn't meet 
the coverage criteria for a continuous glucose monitoring system and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day. Based on this information, we decided that Medicare rules for 
coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a 
therapeutic continuous glucose monitor (CGM)(K0554, K0553).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve echocardiography, transthoracic, complete, with spectral doppler 
echo and color flow doppler (93306). 
 
You asked the Plan to pre-approve the transthoracic echocardiography. You say that the records provided 
should support the necessity of the service in dispute. The Plan denied your request. The Plan says that based 
on the records provided, medical necessity has not been met. 
 
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 transthoracic echocardiography. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a history of atrial fibrillation and mild valvular heart 
disease diagnosed in 2013. She has not had an echocardiograam done in the past 7 years and the 2013 one 
showed mild mitral and aortic valvular insufficiency. Although she is not having worsening symptoms, mitral 
and aortic insufficiency can worsen silently over time and produce LV dilatation and dysfunction. Clinical 
assessment of worsening MR/AR using transthoracic echocardiography in this patient with atrial fibrillation, is 
reasonable given the long time since the prior echocardiogram and the possibility of sub-clinical deterioration 
of valvular or LV function which would necessitate further medical therapy. Based on the CMS coverage 
criteria noted, this would be considered "medically necessary and at a duration and frequency appropriate for 
the service" (a 7 year interval in this instance). 
 
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 transthoracic echocardiography have been met. Therefore, we decided that 
the Plan has to pre-approve echocardiography, transthoracic, complete, with spectral doppler echo and color 
flow doppler (93306).  
 
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 waive the copayment for the office visit provided on August 13, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you should not be responsible for 
this copayment because this office visit was the result of the surgery. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing 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 $15 
copayment for each Medicare-covered primary care provider office visit.  
 
You have been asked to pay a $15 copayment for the office visit. The office visit falls within the 
'Physician/Practitioner services, including doctor's office visits' benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on August 13, 2020. 
  
Your complaint about the surgery was performed in error by the doctor 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 4, 2019, 
through October 31, 2019. 
 
You asked the Plan to pay for the home health services. 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 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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 October 2, 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 home health services 
provided from October 4, 2019, through October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. The Plan denied your request. The Plan says the 
enrollee is clearly performing at the same level as prior to his hospitalization, and it appears he can safely be 
treated at a lower level of care. The Plan also says that the enrollee does not appear to require a SNF admission 
at this time. 
 
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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services rendered on September 16, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. The provider submitted a 
claim for procedure codes 99215 (office visit) and 98943 (extraspinal manipulation). These codes are not 
covered by Medicare when billed by a chiropractor. Therefore, we decided that the Plan does not have to pay 
for the chiropractic services rendered on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Epifix, per square centimeter (Q4186). 
 
You asked the Plan to pre-approve Epifix. You say that the enrollee had a basal cell carcinoma removed from 
the right lateral ankle. Best option for wound healing at this point would be Epifix. The Plan denied your 
request. The Plan says the request for this service/item does not meet the requirements for approval and 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 Epifix. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation is insufficient to demonstrate that the coverage criteria have been met in this 
case. Documentation is lacking in regard to the wound being clean and free of necrotic debris or exudate, and 
having adequate circulation/oxygenation to support tissue growth/wound healing, as evidenced by physical 
examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg). 
 
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, per square centimeter (Q4186).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not considered medically necessary for knee pathology when severe arthritis is present. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee presents with a several month history of left knee pain with swelling. Functional limitations 
are noted in activities of daily living. Clinical exam findings are consistent with imaging evidence of a complex 
medial meniscus tear and radiographic evidence of advanced tricompartmental osteoarthritis. Recent 
conservative treatment has included Tylenol, activity modification, ice and elevation. She wishes to delay total 
knee arthroplasty. Under consideration is a request for left knee arthroscopy/debridement, partial medial 
meniscectomy and chondroplasty. Current evidence based medical literature would not support surgical 
intervention at this time. In the setting of advanced osteoarthritis, a trial of conservative treatment is 
recommended prior to meniscectomy. Detailed evidence of a recent, reasonable and/or comprehensive non-
operative treatment protocol trial and failure has not been submitted. There are no current significant 
mechanical symptoms to support surgery prior to a trial of conservative treatment. Therefore, this request for 
left knee arthroscopy/debridement, partial medial meniscectomy and chondroplasty is not medically reasonable 
and necessary at this time. 
 
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 knee arthroscopy for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for debridement services (CPT 11045) provided to the enrollee. 
 
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 that the claim is denied as a redundant procedure. 
 
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 11045 is "Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each 
additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure). 
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records. Our physician reviewer found the medical 
documents submitted including the EOB indicate that CPT 11042-59 was billed on August 10, 2020. In order 
to bill CPT 11045, CPT code 11042 must be coded first. In this case 11042 was coded, validated and paid and 
11045 per the medical records was used to bill the additional 20 sq cm, or part thereof and is eligible for 
reimbursement. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
debridement services (CPT 11045) provided to the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography services (CPT 95861) provided to 
the enrollee on May 13, 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 payment for this service is the responsibility of the facility. 
 
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 95861 is "Needle electromyography; 2 extremities with 
or without related paraspinal areas." 
 
We asked our coding 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our coding reviewer found per the 
Code of Federal Regulations (CFR) 42 CFR 409.3 and Code of  Federal Regulations (CFR) 412.50, "The 
facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and the outside vendors." Therefore, the payment for 95861 TC is included in the 
facility payment where the service was performed and is the responsibility of the facility. 
 
We looked at this coder'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 pay for needle electromyography services (CPT 95861) provided to the enrollee on May 13, 2020.