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

 
We decided that the Plan does not have to pay for the office visit (99214) provided on March 30, 2020 by an 
out-of-network provider. 
 
You asked the Plan to pay for the office visit. You say that you were told the visit would be covered. The Plan 
denied your request. The Plan says there were network providers available. 
 
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 service 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 office visit (99214) provided on March 30, 2020 by an out-of-network 
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoulder joint surgery. 
 
You asked the Plan to pre-approve shoulder arthroscopy (29805, 29823, 23412, 29826). You say that a should 
joint surgery is medically necessary. The Plan denied your request. The Plan says there is no confirmed rotator 
cuff tear and no trial of physical therapy. 
 
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 shoulder arthroscopy (29805, 29823, 
23412, 29826). Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this enrollee presents status post left shoulder dislocation 
with limited motion and discomfort. Clinical exam findings have documented significantly limited active range 
of motion, mild limitations in passive range of motion, and slight rotator cuff weakness. Conservative treatment 
has included immobilization. The enrollee is unable to have a shoulder MRI. Under consideration is a request 
for shoulder surgery. Current evidence based medical literature would not support proceeding with surgery at 
this time. There is no discussion as to why a diagnostic ultrasound or CT scan would not be indicated to 
evaluate the integrity of the rotator cuff. There is limited exam evidence to support the presence of a rotator 
cuff tear. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial 
and failure has not been submitted. Therefore, this request for shoulder surgery would not be considered 
medically reasonable and necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of shoulder arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve shoulder joint surgery.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve Stelara. You say that the enrollee has already tried and failed Remicade and 
Humira. The Plan denied your request. The Plan says the requested drug is covered under the medical benefit if 
provided incident to a physician visit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligib le for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the 
medication does not represent an expense to the physician and will not be included in the physician's bill, it is 
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Stelara.  
 
Benefits for Stelara 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity prosthesis/ankle-foot orthosis. 
 
You asked the Plan to pre-approve a lower extremity prosthesis/ankle- foot orthosis. You say that the enrollee 
needs the ankle foot orthosis for foot drop. The Plan denied your request. The Plan says the documentation 
does not mention foot drop or any neurological condition that may have caused a foot drop. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF to be a home.  
 
Records show that a lower extremity prosthesis/ankle-foot orthosis is being requested for use in a SNF. 
Therefore, we decided that the Plan does not have to pre-approve a lower extremity prosthesis/ankle-foot 
orthosis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the enrollee needs SNF care. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require 
skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service 
criteria for 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 admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the stay at a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you need SNF care. The Plan denied your 
request. The Plan says the rules for SNF care have not been met. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the stay at a skilled nursing facility (SNF).
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 the nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no identified 
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.   
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. The medical record does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humalog for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Humalog 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the consultation services. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent 
to seek out-of-network care. The Plan says there are equally qualified in-network tertiary specialists available 
to you that can provide the services you are requesting. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the consultation services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD) for the enrollee. 
 
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the documentation fails to indicate that the member has a diagnosis of 
bronchiectasis with his chronic obstructive pulmonary disease. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that a 
HFCWOD is not medically reasonable and necessary for the enrollee in this case. There was no evidence from 
the records suggesting this patient had bronchiectasis or another covered diagnosis. The records do not show 
that the patient is presently using a mechanical in-exsufflation device. The records suggest that the patient is 
relatively stable if the Spiriva and Breo are both used appropriately along with the nasal steroid to help reduce 
secretions. The patient appears to be not consistently taking these medications together as instructed. Therefore, 
it is not clearly shown that the patient has failed standard treatment yet. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for a HFCWOD. 
 
 
 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care services (11011, 14040, 26350, 26765) provided 
September 26, 2019. 
 
You asked the Plan to pay for the wound care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says these codes do not allow assistant surgeon payment. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 
11011, 14040, 26350, & 26765. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this 
procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and 
will not be paid. Based upon this information, we find that Medicare coverage criteria for the wound care 
services have not been met. Therefore, we decided that the Plan does not have to pay for wound care services 
(11011, 14040, 26350, 26765) provided September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT of the abdomen and pelvis (74177) provided on May 16, 
2020. 
 
You asked the Plan to pay for the CT of the abdomen and pelvis. You say that you would like reconsideration 
because this claim denied as a duplicate in error. The Plan denied your request. The Plan says this is a duplicate 
service billed by the same provider on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the CT of the abdomen and pelvis have not been met. Specifically, the record indicates that this 
service has previously been processed and paid to the same provider for the same date of service. The 
documentation submitted does not show that this service was rendered more than once on the billed date of 
service. Therefore, we decided that the Plan does not have to pay for CT of the abdomen and pelvis (74177) 
provided on May 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided May 31, 2020 to June 12, 
2020. 
 
 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the enrollee elected to receive services from an out-of-network 
hospital without authorization. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital care. Our reviewer 
says that the inpatient services at issue do not meet coverage criteria. Our physician reviewer found while 
inpatient care was medically appropriate, the enrollee was stable for transfer to an in-network facility. The out-
of-network post-stabilization inpatient admission was not authorized. 
 
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 inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital care provided May 31, 2020 to June 12, 2020.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth removal (CPT 41899). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has a tooth infection that could 
spread to the heart. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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. Therefore, we decided that the Plan does not have to pre-approve tooth removal (CPT 
41899).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for allergen immunotherapy provided on 
March 31, 2020. 
 
You asked the Plan to waive the copayment for allergen immunotherapy. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct 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 $20 
copayment for specialist visits.  
 
You have been asked to pay the allowed amount of $10.36, which is less than the $20 copayment for allergen 
immunotherapy. Allergen immunotherapy falls within the physician/practitioner services, including doctor?s 
office visits benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for allergen immunotherapy 
provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an office visit provided on January 22, 
2020. 
 
You asked the Plan to waive the deductible for an office visit. You say that you have never had to pay in the 
past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $198 deductible for Medicare Part B services. 
 
You received an office visit on January 22, 2020. The record shows that you are a QI with Medicaid. 
Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had 
paid $0 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the 
allowed amount of $89.45.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $198 deductible for Medicare Part B services. This cost sharing is a 
contractual obligation that had not been met at the time an office visit was received on January 22, 2020. 
Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on 
January 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy provided from October 1, 
2019, through October 31, 2019. 
 
You asked the Plan to waive the copayments for physical therapy. You say that you were not told each physical 
therapy visit would cost $40. You say that you wouldn't have opted for the service if you knew. The Plan 
denied your request. The Plan says the copayments 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). Your contract with the Plan clearly says that you must pay a $40 
copayment for Medicare covered speech and physical therapy services from an in-network provider. 
 
You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is 
$240 ($40/visit x 6 visits = $240). Physical therapy falls within the "Outpatient rehabilitation services" 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 copayments for physical therapy provided from October 1, 
2019, through October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies purchased a supplier on March 
3, 2020. 
 
You asked the Plan to pay for incontinence supplies. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
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 pay for incontinence supplies purchased from 
a supplier on March 3, 2020.