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

 
We decided that the Plan does not have to waive the cost shares for the medical services provided from January 
9, 2020 to April 16, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you have paid everything 
you owe. The Plan denied your request. The Plan says the cost shares 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).  
 
The file shows that you received an eye injection during an ophthalmology visit on January 9, 2020. A $10 
copay was applied for the specialist visit. You were also charged a 20% coinsurance for the injected 
medication. The services fall within the vision care and Medicare Part B drugs benefit categories.  
 
The file shows that you received an injection during an ophthalmology visit on February 20, 2020. A $10 
copay was applied to the office visit. A 20% coinsurance was applied to the injection. The services fall within 
the Medicare Part B prescription drug and vision care benefit categories. 
 
The file shows that you received an injection during an ophthalmology visit on April 16, 2020. A $10 copay 
was applied to the office visit. A 20% coinsurance was applied to the injection. The services fall within the 
Medicare Part B prescription drug and vision care benefit categories. 
 
 
 
The documentation shows 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 cost shares for the medical services provided from January 
9, 2020 to April 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and 2 dental extractions with sedation 
performed by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services to be performed by an oral surgeon. You say that you 
have too many medical conditions and your blood sugar is not controlled. You say that one of your teeth is very 
infected and the other one is broken. You say that you are not able to eat well. The Plan denied your request. 
The Plan says services with an oral surgeon are 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 a 
consultation and 2 dental extractions with sedation performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on March 2, 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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee's chief complaint was hip 
and back pain and hypertension. The available documentation in the case file does not support that the 
requested lumbar-sacral orthosis was medically reasonable and necessary. The documentation in the case file 
does not support that the lumbar-sacral orthosis was ordered for one of the following indications: to reduce pain 
by restricting mobility of the trunk, or to facilitate healing following an injury to the spine or related soft 
tissues, or to facilitate healing following a surgical procedure on the spine or related soft tissue, or to otherwise 
support weak spinal muscles and/or a deformed spine. 
 
We looked at this physician's review, the file, and Medicare rules. 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 lumbar-sacral orthosis (LSO) rendered on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on March 2, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation 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 procedure is under study, and has not yet been determined to be better than other 
methods of management at this time. 
 
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 requested procedure is still considered experimental/investigational at this time and is the subject of 
ongoing clinical trials. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on April 8, 2020 to April 9, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with 
this copayment. You say that you were admitted from the emergency room. 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 $395 
copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $395 copayment per day for days 1-4. There is a $0 copayment for additional 
days for an inpatient hospital stay. You are being asked to pay a total of $395 for an inpatient stay. An inpatient 
hospital stay falls within the 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 waive the 
copayment for an inpatient hospital stay provided by a participating provider on April 8, 2020 to April 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on February 17, 
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 were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an LSO is covered when specific criteria are 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee's chief complaint was back 
pain. The available documentation in the case file does not support that the requested lumbar-sacral orthosis 
was medically reasonable and necessary for the enrollee in this case. An 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 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lumbar-sacral orthosis (LSO) rendered on February 17, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neuro stimulation pulse generator. 
 
You asked the Plan to pre-approve the implantable neuro stimulation pulse generator. You say that the enrollee 
is likely to drive significant therapeutic benefit from neurostimulator treatments. You say that the 
neurostimulator will aid in the enrollee's ability to participate in normal activities of daily living, including job 
duties and increasing blood flow to the affected, which will result in reduced production of pain. The Plan 
denied your request. The Plan says the criteria for coverage 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 pre-approve the implantable neuro stimulation pulse 
generator. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found an implantable neuro stimulation pulse generator is not 
proven effective in the treatment of chronic pain. 
 
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 implantable neuro stimulation pulse generator have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an implantable neuro stimulation pulse generator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says there is no 
documentation of a potential complication related to the procedure. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient services. Our physician 
reviewer found that the clinical record presented does not indicate medical need for inpatient admission. The 
proposed surgery is usually performed as a same-day surgery with a period of observation that can include an 
overnight stay in the hospital. There was no documentation of a complication related to surgery or poorly 
controlled comorbidities that would have required the member to stay in the hospital beyond the observation 
period. The hat the record does not show that the physician reasonably expects the enrollee's necessary hospital 
care will span two midnights. Therefore, the requested inpatient admission is not medically reasonable or 
necessary for the enrollee's 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 inpatient services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services you received on May 11, 
2020. 
 
You asked the Plan to waive the services. The Plan denied your request. The Plan says you are responsible for 
the cost share. 
 
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 $20 
copayment per visit for lab services.  
 
Review of the file shows that you were provided lab services on May 11, 2020. You have been asked to pay a 
$20 copayment for the services. 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 copayment for the lab services you received on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on April 21, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says that 
services rendered by non-participating providers, require prior authorization as outlined in the enrollees 
Evidence of Coverage. 
 
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 did not pre-approve the 
chiropractic services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for chiropractic services provided on April 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 15, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you donated blood in the morning and felt 
dizzy and passed out. You say you opted for your spouse to take you to the emergency room. The Plan denied 
your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 15, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the NESS L300 Go Foot Drop System (E0770 and E1399). 
 
You asked the Plan to pre-approve the NESS L300 Go Foot Drop System. You say that you would like 
reconsideration because the member meets criteria for coverage. The Plan denied your request. The Plan says 
that the records show that the member does not have an intact brain spinal cord and peripheral nerves. 
 
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 NESS L300 Go Foot Drop System. 
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this 
case. Our physician reviewer found The enrollee's neurologist documents that the enrollee has intact lower 
motor units (L1 and below) (both muscle and peripheral nerve), muscle and joint stability for weight bearing at 
upper and lower extremities that can demonstrate balance and control to maintain an upright support posture 
independently, has demonstrated brisk muscle contraction to NMES and has sensory perception electrical 
stimulation sufficient for muscle contraction, possesses high motivation, commitment and cognitive ability to 
use such devices for walking, can transfer independently and can demonstrate independent standing tolerance 
for at least 3 minutes, can demonstrate hand and finger function to manipulate controls, has at least 6-month 
post recovery spinal cord injury and restorative surgery, is without hip and knee degenerative disease, has no 
history of long bone fracture secondary to osteoporosis, and has demonstrated a willingness to use the device 
long-term. 
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 NESS L300 Go Foot Drop System have been met. Therefore, we decided 
that the Plan has to pre-approve the NESS L300 Go Foot Drop System (E0770 and E1399).  
 
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 the iStent procedure for the enrollee. 
 
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied 
your request. The Plan says medication is not being used to reduce pressure in the eye. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee does not have mild or moderate open-angle glaucoma and a cataract, currently 
being treated with an ocular hypotensive medication. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the iStent procedure for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says since the surgery has not been had yet, it is not evidence that hospital-level 
care would be required after the surgery. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the review indicates that there is no documentation provided requiring admission to a 
LTACH after the planed surgical procedure. The enrollee's needs can be provided at a less intense level of care 
such as a skilled nursing facility (SNF). In the SNF he can receive skilled nursing including complex wound 
care. The review has determined that the enrollee does not require services at the LTACH that are not available 
at the acute care hospital where he is currently receiving care. There are no services available at the LTACH 
that the enrollee requires that are not available at the health care setting being offered by the health plan. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on May 22, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that the equipment you 
were given fell out immediately and you feel as though you are being charged for something you aren't using. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $57.71. The total amount you are being asked to pay is $11.54 ($57.71 x 20% = 
$11.54). Durable medical equipment falls within the durable medical equipment 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 coinsurance for durable medical equipment provided by a participating provider on 
May 22, 2020.