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

 
We decided that the Plan does not have to pre-approve an Ability Drive Interface, Hdw, & Software, Mount'n 
Mover Mounting Kit 18" Post Forquantum/ Su, Quantum Alternative Drive Port, Ability Drive Joystick, 13" 
Tablet Computer W Gaze and accessory bar for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the Ability Drive does not have FDA approval and the accessory 
bar does not serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 these services. Our reviewer says that 
an Ability Drive Interface, Hdw, & Software, Mount'n Mover Mounting Kit 18" Post Forquantum/ Su, 
Quantum Alternative Drive Port, Ability Drive Joystick, 13" Tablet Computer W Gaze are not considered 
medically reasonable and necessary in this case. Documentation does not support that this device is reasonable 
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed 
body member. The Ability Drive is a wheelchair control system that uses software, a tablet computer and eye 
tracking to create a "virtual joystick." This device is not proven safe and effective and is not the standard of 
care in the management of this patient's condition and therefore is not medically necessary. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for these items. 
 
We looked at this physician's review, the file, and Medicare rules. The accessory bar at issue in this appeal does 
not serve a purpose that is primarily medical in nature. This item is available to the general public and would be 
helpful even to those who are not sick or injured. 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 
an Ability Drive Interface, Hdw, & Software, Mount'n Mover Mounting Kit 18" Post Forquantum/ Su, 
Quantum Alternative Drive Port, Ability Drive Joystick, 13" Tablet Computer W Gaze and accessory bar for 
the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 28, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare 
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to 
pay for the laboratory services provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray, two additional intraoral 
periapical x-rays, and preventive procedure provided on September 8, 2020. 
 
You asked the Plan to pay for the first intraoral periapical x-ray, two additional intraoral periapical x-rays, and 
preventive procedure. You say that you were not advised that this provider was out-of-network prior to your 
appointment. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit. 
The Plan also says that your intraoral x-rays benefit has been exhausted. 
 
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 unspecified preventive procedure is 
not among those covered under this benefit. The contract lists intraoral x-rays as a covered benefit, and is 
limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray 
on March 5, 2020, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the first intraoral periapical x-ray, two additional intraoral periapical x-rays, and 
preventive procedure provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the genetic laboratory testing provided on 
June 18, 2020. 
 
You asked the Plan to waive the coinsurance for the genetic laboratory testing. You say that you were unaware 
that the cost associated with this test would be so high. You say you cannot afford this bill. 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 20% 
coinsurance for molecular or predisposition genetic testing.  
 
You have been asked to pay $774.60 which is 20% of the allowed amount for the genetic laboratory testing. 
The allowed amount is $3,873. ($3,873 x 20% = $774.60). The genetic laboratory testing falls within the 
Outpatient diagnostic tests and therapeutic services and supplies 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 the genetic laboratory testing provided on June 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits per week and 6 
hours of home health aide services per day. 
 
You asked the Plan to pre-approve 3 home health skilled nursing visits per week and 6 hours of home health 
aide services per day. You say that increased services are medically necessary. The Plan denied your request. 
The Plan says your needs can be met with the approved 4 hours of home health aide services per day and one 
skilled nursing visit a week. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 3 home health skilled nursing visits per 
week and 6 hours of home health aide services per day. Our reviewer says that the requested home health 
services are not medically necessary. Our physician reviewer found the documentation doesn?t support that you 
require additional skilled nursing services or skilled rehab services. You do not require more than the approved 
1 skilled nursing visit or the additional home health assistance hours to effectively provide treatment, care, or 
services in order to improve your condition, perform a maintenance program, or prevent deterioration.  You 
have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
You have not had any falls or injuries or medication changes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 3 home health skilled nursing visits per week and 6 hours of home health aide 
services per day have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home 
health skilled nursing visits per week and 6 hours of home health aide services per day.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the ultrasound of the arteries, the duplex scan of lower extremities, and the duplex scan of the vena cava provided on July 1, 2020.

You asked the Plan to reduce the copayments for the ultrasound and the duplex scans. You say that you had the same procedures done in December 2019 and were only charged $94.03. 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay a total copayment of $323.90 for the ultrasound and the duplex scans. The ultrasound and the duplex scans fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the Annual Notice of Changes was sent on September 16, 2019 which advised that the radiological diagnostic services cost share changed from a 20% coinsurance to a $110 copayment. See chart below.
&#8195;

Date of Service	Service	Allowed Amount	Copayment	Member Liability
July 1, 2020	Ultrasound of arteries	$103.90	$110.00	$103.90
July 1, 2020	Duplex scan of lower extremities	$250.53	$110.00	$110.00
July 1, 2020	Duplex scan of vena cava	$186.38	$110.00	$110.00
Total				$323.90

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 reduce the copayments for the ultrasound of the arteries, the duplex scan of lower extremities, and the duplex scan of the vena cava provided on July 1, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that your needs can be met in a skilled nursing facility. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for non-operative management of a 
hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient 
admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on August 14, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that this injection was too 
expensive. You say that the injection didn't even do anything. 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 $270 
copayment for outpatient surgery.  
 
You have been asked to pay a $270 copayment for an outpatient surgery. The injection that was provided is 
considered an outpatient surgery. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider 
on August 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device. 
 
You asked the Plan to pay for intermittent limb compression device. You say that the enrollee requires the 
device. The Plan denied your request. The Plan says the documentation failed to prove that sufficient evidence 
of four-week trial of conservative therapy. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. A four-week 
trial of conservative therapy demonstrating failed response to treatment is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular home usage of conservative therapy including compression garments, exercise and 
elevation. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic (D6245) and two retainer crowns (D6740 x2) 
provided on July 16, 2020. 
 
You asked the Plan to pay for the pontic and retainer crowns. You say that the dental codes you were billed for 
are close to the codes that your Plan uses. The Plan denied your request. The Plan says these services are not 
covered by the Plan. 
 
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 pontic 
(D6245) and two retainer crowns (D6740 x2) provided on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services with dental codes D0140, D0210, and 
D7970 provided on September 18, 2020. 
 
You asked the Plan to pay for dental codes D0140, D0210, and D7970. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the dental services you 
received with dental codes D0140, D0210, and D7970 are not covered under your supplemental dental 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, dental codes D0140, D0210, and 
D7970 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the dental services with dental codes D0140, D0210, and D7970 provided on September 18, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transthoracic echocardiogram. 
 
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your 
request. The Plan says routine follow-up of a stable patient with no symptoms is not supported. 
 
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 study. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the records, you have known coronary disease, a prior normal echocardiogram, no documented 
cardiac symptoms, no documented cardiac physical exam abnormalities and an unchanged electrocardiogram. 
In this circumstance of a clinically stable patient with a prior normal echocardiogram, the documentation does 
not support the medical necessity for a repeat echocardiogram. 
 
 
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 study have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a transthoracic echocardiogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says you do not have a medical problem that doesn't allow you to position yourself in a 
regular bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed, 
or why positioning of bed in other ways is not feasible. The documentation does not support a need for an 
immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. 
The head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart 
failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is 
not medically necessary. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gradient compression stockings (CPT Code A6530). 
 
You asked the Plan to pre-approve the gradient compression stockings. You say that the stockings are 
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the gradient compression stockings have not been met. Medicare 
says this item does not meet the definition of a surgical dressing. For this reason, we cannot approve this 
request. Therefore, we decided that the Plan does not have to pre-approve the gradient compression stockings 
(CPT Code A6530).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a rhythm electrocardiogram report (93042) provided on May 
14, 2020. 
 
You asked the Plan to pay for a rhythm electrocardiogram report. You say that this should be paid because you 
are contracted with the hospital. The Plan denied your request. The Plan says this is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that separate reporting of ECG rhythm strips and 
cardiac output measurements with critical care E&M services is inappropriate. 
 
We looked at the file and Medicare rules. The code at issue, 93042, was reported with 99285, an E&M service. 
Based on this information, we decided that Medicare rules for coverage of a rhythm electrocardiogram report 
have not been met. Therefore, we decided that the Plan does not have to pay for a rhythm electrocardiogram 
report (93042) provided on May 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided on January 9, 2020, 
through January 18, 2020. 
 
You asked the Plan to waive the copayment for inpatient care. You say that the services should be covered. The 
Plan denied your request. The Plan says the cost share was 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 enrollee's contract with the Plan clearly says that enrollees 
must pay a 4% coinsurance for inpatient hospital care.  
 
The enrollee has been asked to pay a 4% coinsurance for inpatient care. This service falls within the inpatient 
hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on 
the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon 
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient 
care provided on January 9, 2020, through January 18, 2020.