Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 6, 2020 to 
August 8, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the care provided was medically 
necessary. The Plan denied your request. The Plan says that inpatient care was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the patient presented to the emergency room with severe debilitating cramping. Because the 
patient was non-ambulatory, it was reasonable to believe that 2 or more midnights would be necessary given 
the degree of disability the patient presented with. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from August 6, 2020 to August 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64633, 64634). 
 
You asked the Plan to pre-approve facet joint injections. You say that you need these injections to relieve your 
pain. 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 a therapeutic facet joint injection is considered 
medically reasonable and necessary if the patient has had two (2) medically reasonable and necessary 
diagnostic MBBs with each one providing a minimum of 80% relief of primary (index) pain (with the duration 
of relief being consistent with the agent used) or at least 50% improvement in the ability to perform previously 
painful movements and ADLs. 
 
We looked at the file and Medicare rules. The submitted records do not show that you have had 80% pain relief 
from MBBs od 50% improvement performing ADLs. Based on this information, we decided that Medicare 
rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have 
to pre-approve facet joint injections (64633, 64634).
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 the SNF admission. You say that it is felt that this level of care is medically 
necessary. The Plan denied your request. The Plan says the enrollee has not had a 3-day inpatient hospital stay. 
As such, the requested SNF care is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that SNF care may be covered only after a qualifying 
3-day inpatient hospital stay. 
 
In this case, the enrollee was only treated in observation status and was not formally admitted to the facility. 
Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on the treatment of a foot infection 
(28002) and a skin graft (15275, 15276) provided on June 3, 2020. 
 
You asked the Plan to pay for surgical assistant services. You say that these services should be covered. The 
Plan denied your request. The Plan says these codes are not eligible for surgical assistant services. 
 
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 
28002, 15275, and 15276. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these 
procedures. 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 surgical assistant 
services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant 
services on the treatment of a foot infection (28002) and a skin graft (15275, 15276) provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve torus removal and bone replacement graft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
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 torus 
removal and bone replacement graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ankle/foot orthoses and additions to lower 
extremities provided to the enrollee on October 23, 2019. 
 
You asked the Plan to pre-approve these items. The Plan denied your request. The Plan says that the enrollee 
was in a covered Part A stay. 
 
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 or a hospital to be a home.  
 
Records show that these items is being requested for use in a SNF or hospital. Therefore, we decided that the 
Plan does not have to pre-approve the ankle/foot orthoses and additions to lower extremities provided to the 
enrollee on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (X-
Ray) (D0230) provided on October 6, 2020. 
 
You asked the Plan to pay for intraoral X-Ray. You say that the service should be covered. The Plan denied 
your request. The Plan says you have exhausted your plan benefit for this service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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. Specifically, records indicate you have already utilized your 
supplemental benefits for this service. This means the service is not covered. Therefore, we decided that the 
Plan does not have to pay for intraoral - periapical each additional radiographic image (X-Ray) (D0230) 
provided on October 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation (90791) individual 
psychotherapy, 60 minutes, performed by a licensed mental health provider (90837) provided July 22, 2020 to 
August 5, 2020. 
 
You asked the Plan to pay for psychotherapy. You say that it seems to you that since the provider is licensed by 
the state of Connecticut, she meets the requisite qualifying criteria. The Plan denied your request. The Plan 
says the provider does not meet Medicare's standards of non-physician practitioners (other eligible 
professionals). 
 
The Plan must follow Medicare rules. Medicare rules say that that this PPO plan will generally cover your 
medical care as long as the care you receive is considered medically necessary and you receive your care from 
a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider.  
 
We looked at the file and Medicare rules. Medicare only covers the visits when they are provided by a qualified 
health care provider who accepts assignment.  The rendering provider is a licensed marriage and family 
therapist and a licensed professional counselor. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for 
psychiatric diagnostic evaluation (90791) individual psychotherapy, 60 minutes, performed by a licensed 
mental health provider (90837) provided July 22, 2020 to August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for complex cystometrogram (51728) provided on March 12, 
2020. 
 
You asked the Plan to pay for complex cystometrogram. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51728 is complex cystometrogram (ie, calibrated 
electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique. 
 
We asked our coder 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 complex cystometrogram. Our reviewer says that CPT code 
51728 does not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure 
report does not include enough documentation to verify this procedure has been performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of complex cystometrogram have not been met. Therefore, we decided that the 
Plan does not have to pay for complex cystometrogram (51728) provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the laboratory work and the x-ray 
provided from July 20, 2020, to August 5, 2020. 
 
You asked the Plan to waive the copayments for the laboratory work and the x-ray. You say that you believe 
there should not be any copayments for visits prior to September due to the pandemic. The Plan denied your 
request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 
copayment for in-network Medicare-covered laboratory services and a $25 copayment for each in-network 
standard x-ray service.  
 
You have been asked to pay a $5 copayment for the laboratory work on each date of service ($5 x 2 dates of 
service = $10). You have also been asked to pay a $25 copayment for the x-ray. The laboratory work and the x-
ray fall within the ?Outpatient Diagnostic Tests and Therapeutic Services and Supplies? benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the laboratory work and the x-ray provided from July 20, 
2020, to August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Vertiflex Interspinous Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this service 
is medically necessary. The Plan denied your request. The Plan says this service is experimental. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental and more research is needed to show its safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion Vertiflex Interspinous Spacer.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the cost-sharing charges for chiropractic services provided on July 24, 
2020, and July 28, 2020, from $40 to $20.82. 
 
You asked the Plan to reduce the cost-sharing charges for chiropractic services. You say that you should be 
charged 25% coinsurance for out-of-network services not a $20 copayment. You state that the Plan cannot 
change the policy partway through the year. The Plan denied your request. The Plan says that 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 enrollees must pay 25% coinsurance for out-of-network chiropractic services.  
 
You received out-of-network chiropractic services on July 24, 2020. The allowed amount is $41.63 and 25% of 
that is $10.41.   
 
You received out-of-network chiropractic services on July 28, 2020. The allowed amount is $41.63 and 25% of 
that is $10.41.   
 
The total amount you owe is: $20.82.  
 
The Plan says you must pay a $20 copayment for each chiropractic service. Based on the Plan contract, 
however, you cannot be asked to pay more than 25% coinsurance for chiropractic services.  Therefore, we 
decided that the Plan has to reduce the cost-sharing charges for chiropractic services provided on July 24, 2020, 
and July 28, 2020, from $40 to $20.82.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says 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 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided nerve blocks. 
 
You asked the Plan to pre-approve the nerve blocks. You say that you would like reconsideration because you 
suffer from neuropathy. The Plan denied your request. The Plan says the documentation submitted does not 
include any evidence of neuropathy. 
 
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 nerve blocks. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence that a series of 60 injections can provide sustained relief. The literature 
supports a series of 3 injections to determine whether peripheral nerve stimulation may be of benefit. Only a 
small series is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the nerve blocks have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ultrasound guided nerve blocks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 11mg Xeljanz XR tablets. 
 
You asked the Plan to pre-approve the Xeljanz tablets. You say that you would like reconsideration because the 
member is statin intolerant and needs to reduce their cardiovascular risk. The Plan denied your request. The 
Plan says this drug is not covered under 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 11mg Xeljanz XR tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950), prefabricated post and core in 
addition to crown (D2954), endodontic therapy, anterior tooth (D3310), endodontic therapy, premolar tooth 
(D3320), and inhalation of nitrous oxide/analgesia (D9230). 
 
You asked the Plan to pre-approve the core buildup, prefabricated post and core in addition to crown, 
endodontic therapy, anterior tooth, endodontic therapy, premolar tooth, and inhalation of nitrous 
oxide/analgesia. You say that these services are medically necessary. The Plan denied your request. The Plan 
says these services are not covered under the enrollees supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 
core buildup (D2950), prefabricated post and core in addition to crown (D2954), endodontic therapy, anterior 
tooth (D3310), endodontic therapy, premolar tooth (D3320), and inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services provided on May 30, 
2020. 
 
You asked the Plan to waive the copayment for the new patient office visit. You say that you only went for a 
COVID test and you were advised prior that the test would be at no cost. The Plan denied your request. The 
Plan says you were charged the copayment for the specialist office visit 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 $45 
copayment for Physician services. 
 
You have been asked to pay a $45 copayment for the new patient office visit. The physician submitted a claim 
for the office visit. The new patient office visit falls within the Physician Specialist service 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 the specialist services provided on May 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided July 28, 
2020 
 
You asked the Plan to pay for the orthosis. You say that no patient should be denied care or pain management 
solution because they are required to have historical documentation on record to measure pain. The Plan denied 
your request. The Plan says without a face-to-face encounter, the ordering physician couldn?t gather the 
information associated with diagnosing, treating or managing the clinical condition for which the DMEPOS 
were ordered. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
In this case, there were no claims from the ordering/referring within the last 6 months prior to the date of 
service. Without a face-to-face encounter, the ordering physician couldn?t gather the information associated 
with diagnosing, treating or managing the clinical condition for which the DMEPOS were ordered. The record 
shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, 
we decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided July 28, 
2020
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myrbetriq for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has seen great improvement in her 
symptoms with this medication. 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 Myrbetriq 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.