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

 
We decided that the Plan does not have to pre-approve the extraction of erupted tooth (D7140). 
 
You asked the Plan to pre-approve the extraction of erupted tooth. You say that these services are medically 
necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit 
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 pre-approve the 
extraction of erupted tooth (D7140).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have difficulty walking and cannot 
maintain your balance. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the nail plate avulsion provided on May 12, 2020. 
 
You asked the Plan to waive the coinsurance for the nail plate avulsion. You say that you don't think you've 
had this procedure done. The Plan denied your request. The Plan says that the coinsurance applied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Evidence of Coverage was not submitted. This means that we cannot 
determine if the coinsurance amount you are being asked to pay is correct or justified by the Plan contract. 
Therefore, we decided that the Plan has to waive the coinsurance for the nail plate avulsion provided on May 
12, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to make additional payment for the resin-based composite (D2331). We decided 
that the Plan does not have to waive the coinsurance for the resin-based composite (D2331).  
 
You asked the Plan to waive the coinsurance for the resin-based composite (D2331). You say that you thought 
your insurance would pay for the filling because it is covered under your plan. The Plan says that the anterior 
resin-based composite of two surfaces was rendered as a single surface anterior filling procedure. The Plan also 
says that when a procedure is given an alternate benefit, the member is responsible for the difference in allowed 
amounts between the two services. 
 
We decided that the Plan has to make additional payment for the resin-based composite (D2331).  
 
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. 
 
The EOC clearly states that you are only responsible for a 20% coinsurance for white fillings on front (anterior) 
teeth. The Plan has made payment based on the fee for code D2330 ($105), for one surface. The contract does 
not state that if you receive a resin-based composite of two surfaces on a front tooth, you would only be 
covered for one surface and have to pay the difference. As such, the Plan is contractually required to make 
payment based on the fee for D2331 ($133). Therefore, we decided that the Plan has to make this additional 
payment for this service. 
 
We also decided that the Plan does not have to waive the 20% copayment for the resin-based composite 
(D2331). 
 
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, you are responsible for a 20% 
coinsurance for Class 2 Basic Services. You are only responsible for $26.60 (20% of $133). Therefore, we 
decided that the Plan does not have to waive the coinsurance for this service. 
 
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 coinsurance for the infusions provided from June 1, 2020 
to August 12, 2020. 
 
You asked the Plan to waive the coinsurance for the infusions. You say that you were never told of the dollar 
amount and have never been charged additional fees, other than copayments. 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 Medicare-covered Part B drugs and other Medicare-covered items.  
 
You have been asked to pay a total of $4,570 for the infusions. The infusions fall within the "Medicare Part B 
prescription drugs" benefit category. See chart below. Please note, you do not have a coinsurance for the June 
3, 2020 date of service because you met your maximum out-of-pocket amount. 
  
Date of Service Service Allowed Amount Coinsurance Member Liability 
July 9, 2020 Infusion $6,725.15 20% $1,345.03 
June 1, 2020 Infusion $3,180.00 20% $636.00 
June 2, 2020 Infusion $3,180.00 20% $636.00 
August 12, 2020 Infusion $6,725.15 20% $1,345.03 
June 4, 2020 Infusion $3,180.00 20% $607.94  This is 
less than the standard coinsurance amount. 
Total  $22,990.30  $4,570 
 
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 infusions provided from June 1, 2020 to August 12, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower extremity additions for an approved prosthesis. 
 
You asked the Plan to pre-approve lower extremity prosthesis, not otherwise specified (L5999), Addition, 
endoskeletal system, above knee, Custom shaped protective cover, above knee (L5705), Addition, endoskeletal 
system, above knee, flexible protective outer surface covering system (L5964). You say that you need these 
additions. The Plan denied your request. The Plan says these additions exceed the enrollee's needs. 
 
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 lower extremity prosthesis, not 
otherwise specified (L5999), Addition, endoskeletal system, above knee, Custom shaped protective cover, 
above knee (L5705), Addition, endoskeletal system, above knee, flexible protective outer surface covering 
system (L5964). Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found K3 microprocessor knee, vacuum assisted suspension 
system, L5964 extra cover and unbundled L5999 are not medically necessary. The documentation does not 
support that the criteria Local Coverage Determination (LCD): Lower Limb Prostheses (L33787) has been met. 
There is no evidence that the patient is or has the potential to be a K3 ambulator in the treating medical 
practitioner's progress notes. Additionally, L5999 exceeds the patient's needs as the continuous gait assessment, 
computerized microprocessor knee prosthesis of electronically controlled static stance regular adjustable is 
included in the payment for L5856, L5857, or L5858. The L5964 extra cover exceeds the patient's needs as 
there is no evidence that the patient's activities require this additional level of extra protection. The vacuum 
assisted suspension system exceeds the patient's needs and is not medically necessary as the treating medical 
practitioner's progress notes do not support objective evidence on a recent exam that this is needed or that there 
is volume fluctuation of the residual limb. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower extremity prosthesis, not otherwise specified (L5999), Addition, 
endoskeletal system, above knee, Custom shaped protective cover, above knee (L5705), Addition, endoskeletal 
system, above knee, flexible protective outer surface covering system (L5964) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve lower extremity additions for an approved prosthesis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from July 2, 2020, to 
July 26, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says this was not a 
health Plan approved (or covered) SNF, skilled admission. The Plan also says that the enrollee was a known 
custodial resident in this facility since February 2018. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from July 2, 2020, to July 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have a short term memory, bladder leakage, and 
pain associated with it. The Plan denied your request. The Plan says the criteria for admission to the Acute 
Inpatient Rehabilitation setting have not been met. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
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. Our physician 
reviewer also found that 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. 
 
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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 12, 2020, to 
July 11, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 12, 2020, to July 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve this device. You say that this device is medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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, use insulin with at least three daily injections, and require frequent 
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we 
decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a therapeutic glucose monitor for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care billed with a secondary diagnosis code 
of acute respiratory failure with hypoxia (J96.01) provided on May 31, 2018, to June 5, 2018. 
 
You asked the Plan to pay for inpatient hospital care. You say that the record supports the DRG as originally 
billed. The Plan denied your request. The Plan says the medical records fail to support the secondary diagnosis 
and necessitate a change in DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. DRG 190 is defined as chronic 
obstructive pulmonary disease with major complication or comorbidity. 
 
In this case, you billed the services provided May 31, 2018, to June 5, 2018, with DRG 190. 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 inpatient hospital care. Our reviewer says that an incorrect 
DRG code for inpatient care was originally assigned to the enrollee based on their diagnosis. Our physician 
reviewer found the clinical evidence does not support code J96.01 - Acute respiratory failure with hypoxia 
billed as a secondary diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG 190. Therefore, we decided that the Plan does not have to pay for 
inpatient hospital care billed with a secondary diagnosis code of acute respiratory failure with hypoxia (J96.01) 
provided on May 31, 2018, to June 5, 2018.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from June 16, 2020, to 
July 15, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient SNF level of care. 
 
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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from June 16, 2020, to July 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 5, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. 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 September 5, 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 on September 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computerized dynamic posturography provided on July 
17, 2020. 
 
You asked the Plan to pay for the computerized dynamic posturography sensory organization test (92548). You 
say that the medically necessary service was provided in good faith. The Plan denied your request. The Plan 
says this service is investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the computerized dynamic posturography 
sensory organization test (92548). Our reviewer says that the service was not considered medically reasonable 
and necessary in this case. Our physician reviewer found it is unclear why this test was done. Although there is 
literature regarding this test it is not clear why this enrollee needed this test 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 computerized dynamic posturography sensory organization test (92548) 
have not been met. Therefore, we decided that the Plan does not have to pay for the computerized dynamic 
posturography provided on July 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal care services provided from October 7, 2019, to 
November 27, 2019. 
 
You asked the Plan to pay for the personal care 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 provided are not covered. 
 
The Plan must follow Medicare rules. The rules say that Custodial care is not covered. 
 
We looked at the file and Medicare rules. The file shows you are requesting personal care services, also known 
as custodial care. Custodial care includes care that helps people with activities of daily living, like walking, 
getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and 
medications. Custodial care and caregiver services are not covered under your Medicare benefit. Therefore, we 
decided that the Plan does not have to pay for the personal care services provided from October 7, 2019, to 
November 27, 2019.