Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for office visit (99203), trigger point injection 
(20553), radiologic examination (X-Ray) of hip (73502) and betamethasone injection (J0702) provided. 
 
You asked the Plan to waive the deductible for office visit, X-Ray and injections. You say that you have two 
separate claims you paid for and need the money back. The Plan denied your request. The Plan says the cost 
share is correct. 
 
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 a $500 deductible before services are covered in full.  
 
The services you received are subject to the in-network and out-of-network Plan deductible. The Plan has 
followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible. This cost sharing 
is a contractual obligation that had not been met at the time office visit, X-Ray and injections was received on 
April 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for office visit 
(99203), trigger point injection (20553), radiologic examination (X-Ray) of hip (73502) and betamethasone 
injection (J0702) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve 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. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered for enrolles with 
insulin-treated diabetes. 
 
We looked at the file and Medicare rules. The file shows that you are not on insulin. 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 pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan. 
 
You asked the Plan to pre-approve an MRI scan. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan. Our reviewer says that 
the documentation does not support that the requested MRI is medically reasonable or necessary. Our physician 
reviewer found the enrollee has a medical history that includes cervical disc herniation. The documentation 
does not support a recent trial of physical therapy. More conservative measures are needed for neck pain. 
Therefore, the enrollee does not meet criteria for the requested 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 an MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 27, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you were not feeling 
good and were coerced into getting in the ambulance because you were told you would get treated faster at the 
hospital. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 
EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the ambulance services provided on January 27, 2020. Your EOC 
states that enrollees must pay a $225 copayment for each Medicare-covered one-way trip by ground 
transportation. 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 ambulance services provided on January 
27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom ankle-foot orthosis (L1940, L2330). 
 
You asked the Plan to pre-approve the custom orthosis. You say that the orthosis is medically necessary. The 
Plan denied your request. The Plan says a prefabricated orthosis will meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say that custom orthoses are covered when 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 custom orthosis. Our reviewer says 
that the custom orthosis is not medically necessary. Our physician reviewer found the documentation does not 
reveal that the enrollee cannot be fit with a prefabricated 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 the custom orthosis have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a custom ankle-foot orthosis (L1940, L2330).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a non-invasive Osteogenesis stimulator. 
 
You asked the Plan to pre-approve a non-invasive Osteogenesis stimulator. You say that the item is necessary. 
The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has 
not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the noninvasive stimulator device is covered when 
specific criteria is met. 
 
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 non-invasive Osteogenesis stimulator. 
Our reviewer says that the item is medically necessary. Our physician reviewer found the operative record 
documents an L4 through S1 fusion procedure was performed on September 1, 2020. Based on the medical 
records provided there is documentation that the enrollee meets the coverage criteria. 
 
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 non-invasive Osteogenesis stimulator have been met. Therefore, we decided 
that the Plan has to pre-approve a non-invasive Osteogenesis stimulator.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939, 20930). 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate remains experimental at this time. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate (20939, 20930).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence wipes (T4999). 
 
You asked the Plan to pre-approve incontinence wipes. You say that these are medically necessary. The Plan 
denied your request. The Plan says these are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence wipes (T4999).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 28, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
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 requested CPT codes are not supported in the medical record. Specifically, the records 
provided do not show that lab services were performed with blood sampling. The records show that a urine 
specimen was collected. The billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 14 and retainer crowns 
(D6750) for tooth #'s 13 and 15. 
 
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the enrollee needs to save her 
teeth for chewing, and has a long term prognosis for the bridge. The Plan denied your request. The Plan says 
bridges are only covered to replace one front (anterior) tooth. The Plan also says that tooth #'s 13, 14, and 15 
are not anterior teeth. 
 
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 a 
pontic (D6240) for tooth # 14 and retainer crowns (D6750) for tooth #'s 13 and 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surgery. 
 
You asked the Plan to pre-approve these services. You say that your teeth are breaking out as a result of 
radiation treatment. The Plan denied your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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. The services are not covered as a result of radiation treatment. Medicare only covers 
certain dental procedures to prepare the jaw for radiation treatment. Therefore, we decided that the Plan does 
not have to pre-approve dental surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower seating and tilt function for a wheelchair (E1002) for the enrollee.You asked the Plan to pre-approvethe accessories. You say that this is medically necessary.The Plan denied your request. The Plan says this is not indicated for spasticity or bladder management.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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a specialty evalaution by an OT who appears to be employed by the supplier. There is no evidence of intermittent catheterization, spasticity, or high risk of a pressure ulcer. The power seating and tilt function for a wheelchair (E1002) criteria have not been met.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 accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvepower seating and tilt function for a wheelchair (E1002) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tresiba Flextouch for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under Part B. 
 
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 Tresiba Flextouch for the 
enrollee.  
 
Benefits for this drug 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: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve one additional physical therapy visit. 
 
You asked the Plan to pre-approve additional physical therapy visits. The Plan denied your request. The Plan 
says that additional visits are not medically necessary. 
 
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 additional physical therapy visits. Our 
reviewer says that one additional visit is medically necessary. Our physician reviewer found that one additional 
physical therapy visit to update a home exercise program is 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 additional physical therapy visits have been met. Therefore, we decided that the 
Plan has to pre-approve one additional physical therapy visit.  
 
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.

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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a skilled nursing facility. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 an inpatient skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe discharge management services (CPT 99239) provided on January 24, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriateCPT 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, the records do not show that more than 30 minutes of hospital discharge day management services were provided on January 24, 2020. 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 forthe discharge management services (CPT 99239) provided on January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services (CPT 99291) provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. The rules say that critical care is not a service that is paid on a ?shift? 
basis or a ?per day? basis. Critical care service is paid on a time-based service provided on an hourly or fraction 
of an hour basis. For this reason, the documentation provided by the physician must include the amount of time 
in hours and minutes that is spent on providing critical care service. In this case, there is no evidence in the 
medical documentation to show the total time spent delivering critical care to the enrollee. Therefore, we 
decided that the Plan does not have to pay for the critical care services (CPT 99291) provided.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $100 copayment charged for ambulatory surgery provided 
on May 21, 2020. 
 
You asked the Plan to waive this copayment. You say that this copayment was already paid. The Plan denied 
your request. The Plan says this service has a copayment of $100 per the Plan contract agreement. 
 
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 
copayment for this service. If you have already paid the $100 copayment, please contact your provider for 
further information regarding your account. 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 $100 copayment 
charged for ambulatory surgery provided on May 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 additional speech therapy visits (92507).You asked the Plan to pre-approve10 additional speech therapy visits. You say that the services are necessary.The Plandenied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that documentation is expected to support the ability of the beneficiary to learn and retaininstruction.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 10 additional speech therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation in the available records that supports the ability of the enrollee to learn and retain instruction.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of 10 additional speech therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve10 additional speech therapy visits (92507).