Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement K3 Prosthesis (L5987, L5301, L5620, 
L5629, L5637, L5645, L5647, L5679, L5685, L5782, L5910, L5940, L5986, L8420, L8440). 
 
You asked the Plan to pre-approve the replacement prosthesis. You say that the prosthesis 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 a determination of the medical necessity for certain 
components/additions to the prosthesis is based on the beneficiary?s potential functional abilities. 
 
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 replacement prosthesis. Our 
reviewer says that the requested replacement prosthesis is not medically necessary. Our physician reviewer 
found the enrollee currently has a K3 foot. The record does not show why a new socket would not sufficiently 
meet the enrollee's needs. The new requested prosthesis exceeds the enrollee's functional 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 replacement prosthesis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a replacement K3 Prosthesis (L5987, L5301, L5620, L5629, L5637, L5645, 
L5647, L5679, L5685, L5782, L5910, L5940, L5986, L8420, L8440).
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 the member would benefit from continued physician 
management and further inpatient rehabilitation to aid him in regaining prior level of function. The Plan denied 
your request. The Plan says that the enrollee can safely receive the services needed in other settings. 
 
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. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and 
occupational therapy services but based on the medical records provided the patient does not require an 
intensive inpatient rehabilitation therapy program. There is not a reasonable expectation that this patient will be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided from May 9, 2020, to June 
5, 2020. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the charges. The Plan 
denied your request. The Plan says the claims were processed correctly and you are being charged the correct 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for DME and related supplies.  
 
You received DME from May 9, 2020, to May 16, 2020. The total allowed amount is $637.10 and 20% of that 
is $127.43.  
 
You received DME from May 23, 2020, to June 5, 2020. The total allowed amount is $637.10 and 20% of that 
is $127.43. 
 
The total amount you owe is: $254.86.  
 
You have been asked to pay the total coinsurance amount of $254.86 for DME. DME falls within the 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 coinsurance for DME provided from May 
9, 2020, to June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to waive the additional payment for the single surface filling on tooth # 6 
provided on October 2, 2020. 
 
You asked the Plan to waive the additional payment for the dental service. You say that you were quoted $67 
for the filling. You say that you received a bill for an additional $12.50 because the Plan changed the procedure 
code from D2331 to D2330. You say that you reached out to the Plan to inquire about this change. You say that 
you were advised that no valid reason for the change could be given. You also say that you are extremely 
unhappy with the fact that the Plan is able to change a procedure code without notifying you. The Plan denied 
your request. The Plan says that the 2 surface anterior filling procedure was rendered as a single surface 
anterior filling procedure. The Plan also says that when a procedure is given an alternate benefit, the member is 
responsible for the difference in allowed amounts between the 2 services. 
 
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. The Plan covers the dental 
service when the services are medically necessary and reasonable. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental service have been met. Specifically, the Evidence of Coverage clearly states that white 
fillings on an anterior (front) tooth are covered once every 24 months with a 50% coinsurance. Therefore, we 
decided that the Plan has to waive the additional payment for the single surface filling on tooth # 6 provided on 
October 2, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy rendered from March 5, 2020, to 
May 28, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be 
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The 
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare 
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pay for the home infusion therapy rendered from March 5, 2020, to May 28, 2020.  
 
Benefits for these services 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal surgery services (22614, 22612, 22842, 
63047, 63048). 
 
You asked the Plan to pre-approve the spinal surgery services. You say that you would like this claim covered 
and approved for payment. The Plan denied your request. The Plan says the services are not medically 
reasonable and necessary. 
 
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 spinal surgery services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there are no recent imaging studies within the past 6 months documenting 
spinal instability, fracture, or lesion. There are no red flags for surgery at this time. Therefore, the criteria for 
spine surgery 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 spinal surgery services have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the spinal surgery services (22614, 22612, 22842, 63047, 63048).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 14, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that the provider was waiting on a 
script for a COVID-19 test and decided to evaluate you. You feel that for this reason you should not owe a 
copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for specialist services.  
 
You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on September 14, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve magnetic resonance angiography (MRA) services. 
 
You asked the Plan to pre-approve the MRA. You say that you are experiencing severe headaches, are a kidney 
transplant patient, and had fluid found around your brain. You say that the requested MRA is needed to make 
sure you are not going to have an aneurysm. You say that you have polycystic kidney disease, which is known 
to lead to aneurysms. The Plan denied your request. The Plan says that the records do not show that an MRA 
would help your doctor decide if a repair is needed for problems of the head and neck. 
 
The Plan follows Medicare rules. Medicare rules say that MRAs are covered when reasonable and necessary 
for the diagnosis or treatment 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 MRA. Our reviewer says that the 
criteria for coverage have been met. Our physician reviewer found the enrollee has polycystic kidney disease 
and headaches. Our physician reviewer found that polycystic kidney disease is related to berry aneurysms. In 
the presence of a headache, and MRA is not a screening test, but a diagnostic test. Our physician reviewer 
found that the requested MRA is medically reasonable and indicated. 
 
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 MRA have not been met. Therefore, we decided that the Plan has to pre-
approve magnetic resonance angiography (MRA) services.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care 
provided from May 31, 2020 to June 16, 2020. 
 
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says 
that the correct copayment has applied per your contract with the Plan. 
 
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 $0 
copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for Skilled nursing facility 
(SNF) care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received SNF care from April 
29, 2020 through June 17, 2020. You have been asked to pay a $0 copayment per day for days 1-20 of the SNF 
care provided from April 29, 2020 through May 30, 2020. You have been asked to pay a $178 copayment per 
day for days 21-37 of the SNF care provided from May 31, 2020 through June 16, 2020, totaling $3026. The 
SNF care falls within the Skilled nursing facility (SNF) 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 the skilled nursing facility (SNF) care provided from May 31, 2020 to June 16, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen panel provided on July 8, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says code 87631 is 
non-covered and excluded from coverage. 
 
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 looked at the file and the rules. Tests that include more than 5 viral pathogens are non-covered. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the respiratory pathogen panel provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retrograde filling (D3430) and cone beam CT capture and 
interpretation (D0364) provided on March 17, 2020. 
 
You asked the Plan to pay for the retrograde filling and cone beam CT capture and interpretation. You say that 
the dentist did not call for a pre-authorization because you were in excruciating pain at the time. The Plan 
denied your request. The Plan says these services are not covered by your dental plan. 
 
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 pay for the 
retrograde filling (D3430) and cone beam CT capture and interpretation (D0364) provided on March 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on June 2, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that the services were due to 
COVID-19 and the copayment should be waived. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
You received ambulance services on June 2, 2020. Ambulance services are not part of the COVID-19 waiver 
and are subject to cost-sharing charges. Therefore, you are responsible to pay the $250 copayment.  
 
You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on June 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 8, 2020 by an out of 
network(OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 physician services provided on July 8, 2020 by an 
out of network(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for technetium tc-99m tetrofosmin (A9502) and regadenoson 
injections (J2785) provided on April 24, 2020. 
 
You asked the Plan to pay for technetium tc-99m tetrofosmin and regadenoson injections. You say that this is 
supported in the records. The Plan denied your request. The Plan says this is not documented. 
 
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 A9502 and J2785 are not supported in the medical record. Specifically, there is no 
documentation of these medications being administered. Based on this information, we decided that Medicare 
rules for coverage of technetium tc-99m tetrofosmin and regadenoson injections have not been met. Therefore, 
we decided that the Plan does not have to pay for technetium tc-99m tetrofosmin (A9502) and regadenoson 
injections (J2785) provided on April 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on June 25, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services 
were included in the APC payment. 
 
The Plan must follow Medicare rules. Medicare rules say that if a claim contains services that result in an APC 
payment but also contains packaged services, separate payment for the packaged services is not made since 
payment is included in the APC. 
 
The file shows that the enrollee received collection of blood and Thyroxine testing services during hospital 
outpatient clinic visit. The lab services are packed services, and not separately payable. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the lab testing provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for electrical stimulation (unattended), to one or more areas for 
indication(s) other than wound care, as part of a therapy plan of care (CPT Code G0283), application of a 
modality to 1 or more areas; hot or cold packs (97010) and therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110) 
provided on September 2, 2020. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary and reasonable. 
The Plan denied your request. The Plan says the services are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for electrical stimulation (unattended), to one or more areas for indication(s) 
other than wound care, as part of a therapy plan of care (CPT Code G0283), application of a modality to 1 or 
more areas; hot or cold packs (97010) and therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic 
exercises to develop strength and endurance, range of motion and flexibility (97110) provided on September 2, 
2020.