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

 
We decided that the Plan does not have to pre-approve a complete maxillary denture. 
 
You asked the Plan to pre-approve the complete maxillary denture. You say that you got your dentures over 
seven years ago. You also say that you need an upper replacement denture. The Plan denied your request. The 
Plan says this service is limited to one time every 60 months. The Plan also says that you had this service less 
than 60 months ago. 
 
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, dentures are limited to one set every 5 
years. The record shows that you received a complete maxillary denture on November 23, 2016, and your 
maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve 
a complete maxillary denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician services (99213) provided May 
18, 2020. 
 
You asked the Plan to waive the copayment for the physician services. You say that this was an annual 
wellness visit and there should be no copayment. The Plan denied your request. The Plan says the record shows 
there were additional services performed that go beyond the annual wellness visit, and therefore, the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for office visits.  
 
You have been asked to pay a $20 copayment for the physician services. The physician services fall within the 
office visits benefit category. The record shows the services were not limited only to a wellness visit. 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 physician services (99213) provided May 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. The Plan denied your request. The Plan says 
there is no qualifying wound. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are 
non-covered 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 A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for collagen dressing, sterile (A6021) tape, 
waterproof (A4452) conforming bandage, sterile (A6446) gauze, non-impregnated, sterile (A6402) provided 
from July 28, 2020, to August 28, 2020. 
 
You asked the Plan to waive the copayment for the wound care supplies. You say that you are appealing for 
multiple dates of service because you were not in the office on those dates and they have billed too much. You 
were present for 8/28/20 but the charges are absorbent. The Plan denied your request. The Plan says the claim 
was processed and the correct coinsurance was applied per the Evidence of Coverage. 
 
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 DME, oxygen/oxygen equipment and related supplies.  
 
You have been asked to pay $237 coinsurance for the wound care supplies. The wound care supplies fall within 
the Durable medical equipment (DME) and related 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 copayment for collagen dressing, sterile (A6021) tape, waterproof (A4452) conforming bandage, 
sterile (A6446) gauze, non-impregnated, sterile (A6402) provided from July 28, 2020, to August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90792) provided on 
January 28, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the claim should be paid. The 
Plan denied your request. The Plan says the claim was not received within the 365 day timely filing period. 
 
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 psychiatric diagnostic evaluation was not filed until September 8, 2020. 
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 a psychiatric diagnostic evaluation (90792) 
provided on January 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter. 
 
You asked the Plan to pre-approve an electric scooter. You say that you would like a scooter to go to the 
grocery store because you can walk that far but you get tired. The Plan denied your request. The Plan says your 
physical therapy assessment shows you are able to ambulate independently and safely with a cane within your 
apartment. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. Also, 
the item at issue in this appeal is being requested for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. 
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electric scooter.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do 
not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Volara Oscillation Lung Expansion System. 
 
You asked the Plan to pre-approve a Volara Oscillation Lung Expansion System. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that Intrapulmonary Percussive Ventilator (IPV) is 
non-covered. 
 
Review of the file shows that the plan uses Local Coverage Article (LCA), A57742 to support their denial. 
However, LCA A57742 is not valid for the enrollees home state of Michigan. Therefore, we cannot use LCA 
A57742 to substantiate our decision. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Volara Oscillation Lung Expansion System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Volara Oscillation Lung Expansion System.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on 
March 10, 2020. 
 
You asked the Plan to pay for the determination of refractive state. 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 
under your supplemental vision benefit if not provided by a preferred provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a preferred provider. 
 
We looked at the file and the Plan's rules. The Plan's contract clearly says that routine eye exams (refractions) 
are covered only when provided by a preferred provider. The file shows you received your determination of 
refractive state services with a non-preferred provider. Based on this information, we decided that the Plan's 
rules for coverage of the determination of refractive state have not been met. Please note you are not 
responsible for the payment of $95 for the diagnostic imaging (92134) as this was denied as provider liability. 
Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) 
provided on March 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(0275T). 
 
You asked the Plan to pre-approve these services. You say that your pain is getting worse and has no relief. 
The Plan denied your request. The Plan says that your request is not a covered benefit because your records do 
not show that you are enrolled in an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous image-guided lumbar 
decompression is covered if you are enrolled in an approved clinical study. 
 
We looked at the file and Medicare rules. The file does not indicate you are enrolled in a clinical study. 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 percutaneous image-guided lumbar 
decompression (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 13, 2020, by an 
OON provider. 
 
You asked the Plan to pay for a shingles vaccine administration. You say that you should be allowed to see the 
doctor of your choice. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 had network providers 
available who could have provided 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 the medical services provided on August 13, 2020, 
by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Monovisc and Orthovisc first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the review indicates that the 
enrollee is with osteoarthritis of the knee. His provider has requested Euflexxa. The Plan requires a trial of 
Monovisc and Orthovisc first before they will approve the requested drug. In this case the enrollee has not tried 
and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 
would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient lab testing provided on October 
10, 2019, and the specialist office visit with a cardiologist provided on October 23, 2019. 
 
You asked the Plan to waive the copayment for lab testing and a specialist office visit. You say that you were 
invited for a visit with the doctor and did not expect to have a copay. The Plan denied your request. The Plan 
says outpatient laboratory testing has a $20 copay. The Plan also says that because you have a qualifying 
condition, you have been invited to participate in a special program to help you manage it. You are allowed to 
see a specialist for four visits within a year with a $10 copay rather than the usual rate. 
 
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 
copay for outpatient lab testing and a $10 copay for a specialist office visit because you have a qualifying 
chronic condition.  
 
You have been asked to pay a $20 copay for lab testing and a $10 copay for a specialist office visit. Lab testing 
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The 
specialist office visit falls under the Help with Certain Chronic Conditions benefit category because you have a 
qualifying condition. 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 outpatient lab testing provided 
on October 10, 2019, and the specialist office visit with a cardiologist provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 26, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the documentation is missing required information. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
Review of the file shows that this item was prescribed by a provider without a face-to-face evaluation, physical 
examination, or imaging demonstrating medical necessity. The reasonableness of the provided durable medical 
equipment is not established. This means that the telehealth visit is not a covered service under the Medicare 
program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following 
the noncovered visit are likewise noncovered.  
 
Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 26, 
2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided  on August 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 August 29, 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 August 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT scan) of the abdomen 
(74170). 
 
You asked the Plan to pre-approve a CT scan of the abdomen. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan of the abdomen. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found a follow up CT for 
surveillance would not be considered medically necessary due to the lack of clinical findings or history to 
support a malignant process as well as the stable nature including low attenuation coefficient of less than 10 
Hounsfield units consistent with a benign adenoma. 
 
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 CT scan of the abdomen have not been met. Specifically, the CT is not 
reasonable or necessary. Therefore, we decided that the Plan does not have to pre-approve a computed 
tomography (CT scan) of the abdomen (74170).
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says rules for IRF care 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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, the 
patient does 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. Finally, 
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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care and inpatient care you 
received from June 24, 2020, to July 21, 2020. 
 
You asked the Plan to waive the copayment. 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 $90 
copayment for each covered emergency room visit. Your contract also says that you must pay a $375 
copayment per day for days 1-5 for each inpatient hospital stay. 
 
Review of the file shows that you were provided emergency care on June 24, 2020. You have been asked to 
pay a $90 copayment for the services. The services fall within the emergency care benefit category. The 
records also show that you were provided 6 days of inpatient care from July 15, 2020, to July 21, 2020. You 
have been asked to pay a $375 per day for the first five days of this stay, totaling $1,875. 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 emergency care and inpatient care you received from June 24, 
2020, to July 21, 2020.