Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acetaminophen/codeine 300-30mg tablets. 
 
You asked the Plan to pre-approve the acetaminophen/codeine tablets. You say that the enrollee requires this to 
treat the pain she has been experiencing. The Plan denied your request. The Plan says this is an oral drug and is 
not covered by Medicare 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 acetaminophen/codeine 
300-30mg tablets.  
 
Benefits for the acetaminophen/codeine tablets 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the bladder tests you had on January 29, 
2020, and February 19, 2020. 
 
You asked the Plan to waive the copayments for the bladder tests. You say that you would like to appeal these 
charges. The Plan denied your request. The Plan says you were charged these amounts correctly.  The plan says 
that because the allowed amount for each of these tests ($10.96) is less than your copayment obligation, you 
are responsible for the full amount for these tests. 
 
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 $30 
copayment for non-radiological diagnostic services and tests.  
 
You have been asked to pay a $30 copayment for the bladder tests. The bladder tests fall within the non-
radiological diagnostic services and 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 copayments 
for the bladder tests you had on January 29, 2020, and February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 10, 2018, to October 31, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until December 23, 2019. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided from October 10, 2018, to October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to treat 
lymphedema. The Plan denied your request. The Plan says these compression stockings are never covered 
because they do not meet the statutory definition of a surgical dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities coded 97110, 97112, and 97530 
provided on January 9, 2020. 
 
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 97110, 97112, and 97530 are not supported in the medical record. Specifically, the 
documentation submitted did not include documentation of therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; therefore, 
code 97110 cannot be verified. The documentation submitted does not support documentation of therapeutic 
procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, 
kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; therefore, code 97112 
cannot be verified. The documentation submitted did not include documentation of therapeutic activities, direct 
(one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes; 
therefore, code 97530 cannot be verified. Based on this information, we decided that Medicare rules for 
coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to 
pay for the therapeutic activities coded 97110, 97112, and 97530 provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the Epifix wound care product 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 that medical studies have not proven that this device is helpful for treatment of the 
health problem. 
 
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 services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found this is needed to prevent recurring wound opening. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve the Epifix wound care product for the enrollee.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that it is felt that the LTACH level of care is 
necessary. The Plan denied your request. The Plan says criteria for transfer to an LTACH have not been met. 
 
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 enrollee was admitted to the acute care hospital on 10/18/20 with shortness of 
breath due to congestive heart failure versus pneumonia, and sepsis. The enrollee was placed on BiPAP. The 
enrollee suffered a cardiac arrest on 10/19/20. A tracheostomy and PEG tube were placed on 10/28/20.  
 
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not 
provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee 
is receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where she is currently receiving care. The requested LTACH services are/are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray rendered on May 1, 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 procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 36558. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 36558. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided on June 19, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 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. The Plan did not pre-approve the item/service at 
issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for out of network medical services provided on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you need the compression 
stockings for circulation in your legs. The Plan denied your request. The Plan says the compression stockings 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nutritional formula (B4154). 
 
You asked the Plan to pre-approve the nutritional formula. You say that the formula is medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enteral nutritional formula is covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the nutritional formula. Our reviewer 
says that the formula is not medically necessary. Our physician reviewer found the enrollee does not currently 
have a feeding tube. Enteral nutritional formula is not covered in the absence of a feeding tube. 
 
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 nutritional formula have not been met. Therefore, we decided that the Plan 
does not have to pre-approve nutritional formula (B4154).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study you received on October 4, 
2019. 
 
You asked the Plan to waive the copayment. You say that you were told there would be no charge for sleep 
study. The Plan denied your request. The Plan says you are responsible for the copayment. 
 
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 $170 
copayment for each covered diagnostic procedure or test at a network outpatient facility.  
 
Review of the file shows that you had a sleep study on October 4, 2019. Per your contract with the Plan, there 
is a $170 copayment for a sleep study. However, the sleep study has a Medicare allowed amount of $139.43. 
Since the Medicare allowed amount was less than the $170 copayment, you have been asked to pay the lesser 
amount. 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 sleep study you received on October 4, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Lifevest for the enrollee. 
 
You asked the Plan to pre-approve the vest. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records provided indicate an arrhythmia, and the ejection fraction is greater than 
35%. 
 
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 vest. Our reviewer says that the 
requested vest is not considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee has a documented ejection fraction over 35%, and no record of unexplained syncope, sustained 
ventricular tachycardia or inducible ventricular tachycardia. Therefore coverage criteria for an external 
(wearable) defibrillator is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the vest have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Lifevest for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant (D6010), a prefabricated abutment (D6056), 
and an implant supported crown (D6066). 
 
You asked the Plan to pre-approve the dental services. You say that you do not want dentures. You say that you 
only want an implant. You also say that you do not want, nor did you ask, for a prior authorization for dentures. 
The Plan denied your request. The Plan says implant is not listed as a covered service. The Plan says 
prefabricated abutment is not listed as a covered service. The Plan also says implant supported crown is not 
listed as a covered service either. 
 
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 an 
implant (D6010), a prefabricated abutment (D6056), and an implant supported crown (D6066).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 26, 2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for out of network physician services provided on 
June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your records show you do not have daily skilled therapy or skilled 
nursing needs. 
 
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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the enrollee needs to resume CPAP therapy. 
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 beneficiaries who fail the initial 12 week trial are 
eligible to re-qualify for a PAP device but must have both an in-person clinical re-evaluation by the treating 
practitioner to determine the etiology of the failure to respond to PAP therapy; and a repeat sleep test in a 
facility-based setting. 
 
We looked at the file and Medicare rules. The submitted medical records show that the enrollee failed a 
previous trial of PAP therapy, but they do not show that the enrollee has had a repeat sleep test or an evaluation 
to determine the etiology of the failure to respond to PAP therapy. Based on this information, we decided that 
Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics at the in-network benefit level from an 
out-of-network provider. 
 
You asked the Plan to pre-approve the foot orthotics at the in-network benefit level. You say that the orthotics 
were approved at the in-network level last year and you would like the same benefit. The Plan denied your 
request. The Plan says while they approve the diabetic shoes and inserts, they are available in-network, 
therefore there is no network deficiency. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Although the orthotics are approved the Plan does not have to approve them at the in-network level. The Plan 
has network providers available who can provide the items at issue in this appeal. Therefore, we decided that 
the Plan does not have to pre-approve foot orthotics at the in-network benefit level from an out-of-network 
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance services provided by you 
on June 19, 2020. 
 
You asked the Plan to waive the co-payment for the ambulance services. You say that this was medically 
necessary. 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 pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to waive the co-payment for are ambulance transport services to a 
doctor's office. Therefore, we decided that the Plan does not have to waive the co-payment for the ambulance 
services provided by you on June 19, 2020.