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

 
We decided that the Plan does not have to waive the coinsurance for the MRI, brain (including brain stem); 
without contrast material provided on February 19, 2020. 
 
You asked the Plan to waive the coinsurance for the MRI. You say that you have never had a copayment for 
this procedure and had had it done yearly over the past several years. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received an MRI on February 19, 2020. You are asked to pay a $200 
copayment for an MRI. Your EOC states, enrollees must pay a $0 or $200 copayment for Medicare-covered 
diagnostic radiology services (not including x-rays). This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the MRI, brain (including brain stem); without contrast material provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on March 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on March 17,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS device. 
 
You asked the Plan to pre-approve a TENS device. You say that this device will help you control your back 
pain. The Plan denied your request. The Plan says that the documentation fails to indicate that you are enrolled 
in an approved study. 
 
The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered when the above criteria 
are met. 
 
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 a TENS device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a TENS device.
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 the IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided you do not require treatment in an intensive rehabilitation therapy program. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone replacement graft (D4263) and tissue 
regeneration (D4266). 
 
You asked the Plan to pre-approve the bone replacement graft (D4263) and tissue regeneration (D4266). You 
say that you want to have this approved. The Plan denied your request. The Plan says the services are not 
covered benefits. 
 
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 
bone replacement graft (D4263) and tissue regeneration (D4266).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that aggressive speech therapy for cognitive linguistic 
improvement is needed. The Plan denied your request. The Plan says the enrollee may be equally well served at 
an alternate level of care. 
 
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 records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication 
management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of 
therapy 
will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not 
warranted. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapy needs can continue to be provided at a lower level 
of care such as a skilled nursing facility or on an intermittent basis utilizing the member's Part B benefits on an 
outpatient basis. 
 
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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. A less intensive, longer duration of therapy will allow for measurable gains 
to be attained within a reasonable and predicted period. Our physician reviewer found that the enrollee's 
condition does not meet Medicare criteria for IRF care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and extraction to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve the consultation and extraction. You say that you need to have your tooth 
removed. The Plan denied your request. The Plan says your contract only covers dental services when they are 
performed by a participating general dentist. The Plan also says that dental services performed by an oral 
surgeon 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 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a consultation and extraction to be provided by an oral surgeon.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on January 28, 
2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were not admitted 
as inpatient because there were no beds available at the hospital. The Plan denied your request. The Plan says 
the copayment you are being charged is correct. 
 
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 $50 
copayment for each emergency room visit in the U.S. Your contract with the Plan also clearly says that if you 
are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. 
 
You were not admitted to the hospital under inpatient care within 24 hours, therefore the $50 emergency room 
visit copayment applies to this claim. An emergency room visit falls within the emergency care 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 an emergency room visit on January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary, as there 
would be a physician on staff that could provide a higher level of care needed that a skilled nursing facility 
could provide. The Plan denied your request. The Plan says the course of care in the acute care hospital has not 
been completed. 
 
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 is currently undergoing treatment at an ACH for an infected/necrotic 
wound. The enrollee has received debridement, wound care and antibiotics. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term 
care needs. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the PET scan with concurrently acquired CT scan for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) provided on March 18, 2020.
You asked the Plan to waive the coinsurance for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a PET scan on March 18, 2020. You are asked to pay a $300 copayment for the PET scan. Your EOC states, enrollees must pay a $300 copayment for diagnostic radiology other than CT scans. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the PET scan with concurrently acquired CT scan for attenuation correction and anatomical localization imaging; skull base to mid-thigh (78815) provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services you provided from October 18, 2019 to 
December 20, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 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 physician's services you provided from October 18, 2019 to 
December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Prokera amniotic membrane (V2790). 
 
You asked the Plan to pre-approve a Prokera amniotic membrane. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that use of amniotic membranes outside of the care of 
venous stasis ulcers and diabetic foot ulcers will be denied as not reasonable and necessary and non-covered. 
 
We looked at the file and Medicare rules. The records show that this is being requested for the treatment of 
keratitis. The records do not show that the enrollee has venous stasis ulcers or diabetic foot ulcers. Based on 
this information, we decided that Medicare rules for coverage of a Prokera amniotic membrane have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Prokera amniotic membrane (V2790).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve combination sit to stand frame/table system, any size 
including pediatric, with seat lift feature, with or without wheels (E0637). 
 
You asked the Plan to pre-approve the DME. You say that you have blisters on your feet, it is painful and you 
cannot walk right now. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
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 DME. Our physician reviewer 
found based on the documentation provided, it is my opinion that the health plan's denial should be upheld. 
There is no evidence that the enrollee has severe arthritis or a neuromuscular disease. There is no evaluation of 
the enrollee's mobility. There is no assessment or plan to provide the enrollee with a seat lift mechanism. 
Therefore, the documentation does not support that the requested seat lift mechanism is currently medically 
necessary or reasonable. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve combination sit to stand frame/table system, any size including pediatric, with seat lift feature, 
with or without wheels (E0637).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 01922 provided on November 5, 2019. 
 
You asked the Plan to pay for CPT code 01922. 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. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file, the Plan's contract and Medicare rules. The documentation submitted did not include 
documentation of the name of the servicing provider and the billed service cannot be verified. Therefore, we 
decided that the Plan does not have to pay for CPT code 01922 provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home blood pressure cuff.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve a home blood pressure cuff.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that the requested grab bars are a necessity for you
because of your back problems. You say that you have severe spinal stenosis and nerve compression. You
stated that you cannot safely get in or out of your bathtub without the grab bars because of your condition. You
asked the Plan to reconsider providing coverage. 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 grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of mammary implant material services to be provided at the in-network rate by an out of network (OON) provider.
You asked the Plan to pre-approve the removal of mammary implant material services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 removal of mammary implant material services to be provided at the in-network rate by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on March 25, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told that there would be no 
charge for the CT scan. 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 $300 
copayment for other outpatient diagnostic tests. For this date of service, you have been asked to pay the 
allowed amount of the claim because this amount is less than the $300 copayment for the CT scan. 
 
You have been asked to pay a $209.64 copayment for the CT scan. The CT scan falls 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 copayment for the CT scan provided on March 25, 2020.