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

 
We decided that the Plan does not have to preapprove a knee orthosis (L1852). 
 
You asked the Plan to preapprove  the knee orthosis. You say that the orthosis should be covered. The Plan 
denied your request. The Plan says knee braces (knee orthosis) requested does not meet the requirements for 
approval. 
 
The Plan must follow Medicare rules. Medicare rules say that for knee braces under code L1852 to be covered 
knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 
This can also be covered if there is recent injury to the knee or a surgical procedure on the knee.  
 
The request is not medically necessary because the records do not show that there is instability, laxity, recent 
injury, or surgical procedure done to the knee. Therefore, we decided that the Plan does not have to preapprove  
a knee orthosis (L1852).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee orthosis provided on March 13, 2020.
You asked the Plan to waive the coinsurance for the knee orthosis. You say that the provider called the Plan prior to prescribing the boot and was informed by the Plan that there was no member financial responsibility. The Plan denied your request. The Plan says there was no indication you contacted the Plan prior to verify benefits and no misinformation was provided.
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 the knee orthosis provided on March 13, 2020. You are asked to pay 20% coinsurance for the knee orthosis. Your EOC states that enrollees must pay 20% coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics. 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 knee orthosis provided on March 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from February 6,
2020 through February 17, 2020 provided by an out-of-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told there would
be no copayment. The Plan denied your request. The Plan says they verified that the provider is not a network
provider with the Plan. You state 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 shows that you were admitted on February 6, 2020 and discharged on February 17, 2020.
You were asked to pay a $175 copayment per day from February 6, 2020 through February 10, 2020, days 1-5
of your inpatient stay. There were no copayment charges from February 11, 2020, day 6 of your inpatient
hospital care until your day of discharge February 17, 2020. Per your contract there is a $175 copayment per
day required for days 1-5. For inpatient hospital care, the cost-sharing described above applies each time you
are admitted to the hospital. 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 inpatient hospital care from
February 6, 2020 through February 17, 2020 provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the home visit (99341) and debridement (11721). You say that you would like reconsideration because this provider is in-network with the Plan. The Plan denied your request. The Plan says medically necessary services were available within the network and there were no extenuating circumstances making it medically necessary to obtain the service out-of-network.
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 the medical services provided on November 22, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says both thermal and cooled manners of genicular radiofrequency ablation are still being 
studied to determine if these are safe and effective alternative treatments to standard therapies for knee pain due 
to osteoarthritis or in the setting of replacing or significantly delaying total knee arthroplasty. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure which is the subject of several ongoing clinical 
trials. No learned society has incorporated this procedure into a practice guideline. Therefore, the request is 
considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a surgical skin biopsy provided on November 1, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that you paid $40 to see your specialist at the time of service and were not in an operating room, so should not have to pay this charge. The Plan denied your request. The Plan says the copayment amount 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 $270 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay the allowed amount of $199.82, which is less than the $270 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 surgical skin biopsy provided on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for physical therapy for TMJ provided on February 10, 2020 and February 24, 2020.
You asked the Plan to pay for the physical therapy. You say that you had a problem with dislocation of the joint. You say that therapy was recommended to fix the problem. The Plan denied your request. The Plan says that coverage is not provided for this diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 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 pay for physical therapy for TMJ. Our reviewer says that the criteria for coverage has been met. Our physician reviewer found the documentation supports that the physical therapy is addressing a medical condition and is not a dental issue. Our physician reviewer found there is some dysfunction noted in the right joint which caused noted changes in joint function along with joint sounds. Our physician reviewer says the physical therapy is medically reasonable and necessary to address the sudden change in joint function on the right side. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy for TMJ have been met. Therefore, we decided that the Plan has to pay for physical therapy for TMJ provided on February 10, 2020 and February 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided out of network on March 2, 
2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physician services provided out of network on 
March 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay in full for emergency care (99281) provided on November 20 to 
November 21, 2019 onboard a cruise vessel. 
 
You asked the Plan to pay in full for the emergency care. You say that since the services were provided in 
international waters, the full amount should be covered. The Plan denied your request. The Plan says the plan is 
only responsible for up to the Medicare allowed amount. The plan says that the records show the ship was in 
Key West, Florida at the time services were rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that the plan must pay for emergency and urgently 
needed services. 
 
We looked at the file and Medicare rules. Regardless of the location of the ship at the time services were 
rendered, the plan is only liable for up to the Medicare allowed amount for CPT code 99281, which is $23.64. 
If the ship is within 6 hours of arriving at a U.S. port, Medicare coverage rules apply which would limit 
payment to the allowed amount. Otherwise, the plan's rules for coverage of emergency care outside the U.S. 
apply which still limit coverage up to the Medicare allowed amount as if the services were rendered in the U.S. 
Therefore, we decided that the Plan does not have to pay in full for emergency care (99281) provided on 
November 20 to November 21, 2019 onboard a cruise vessel. The record shows the plan has already paid the 
allowed amount of $23.64.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of the 
chest (71250) provided April 2, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. 
The Plan denied your request. The Plan says 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 $270 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay the Medicare allowable amount of $165.46 copayment for the CT scan. The CT 
scan falls within the outpatient diagnostic tests benefit category. The allowable amount is less than the amount 
noted in the plan contract. 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 Computed Tomography 
(CT) scan of the chest (71250) provided April 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the ambulance transports provided on March 
13, 2020 and March 14, 2020. 
 
You asked the Plan to waive the copays for the ambulance transports. You say that you should not be charged 
because these were emergency situations. The Plan denied your request. The Plan says that you owe cost 
sharing for these services. 
 
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 $200 
copay for Medicare-covered ambulance services.  
 
You have been asked to pay a $200 copay for each of the ambulance transports. The ambulance transports fall 
within the Medicare-covered 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 
copays for the ambulance transports provided on March 13, 2020 and March 14, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a complete maxillary denture (D5110) and a complete mandibular 
denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. The Plan denied your 
request. The Plan says that an x-ray was not included in the initial request. The Plan also says that the x-ray 
was not transferred to the appeals department timely. 
 
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 a 
complete maxillary and mandibular dentures when the services are medically necessary and reasonable. 
 
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 a complete maxillary and 
mandibular dentures. Our reviewer says that the services meet the Plan's coverage criteria. Our physician 
reviewer found the documentation provided meets the criteria for coverage for complete maxillary (D5110) and 
mandibular (D5120) dentures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the a complete maxillary and mandibular dentures have been met. Therefore, 
we decided that the Plan has to pre-approve a complete maxillary denture (D5110) and a complete mandibular 
denture (D5120).  

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 Acetaminophen, Celecoxib, Gabapentin, Ibuprofen, 
Lidocaine, Amlodipine, Docusate Sodium, and Levothyroxine provided on March 3, 2020 and March 4, 2020. 
 
You asked the Plan to pay for the Acetaminophen, Celecoxib, Gabapentin, Ibuprofen, Lidocaine, Amlodipine, 
Docusate Sodium, and Levothyroxine. You say that you never considered bringing your own medications to 
the hospital to be given to you post-surgery. You also say that you do not think it is fair that you have to pay for 
drugs that you needed while you were hospitalized. The Plan denied your request. The Plan says these drugs 
are self-administered. The Plan also says that your medical benefit does not cover self-administered drugs. 
 
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 pay for the Acetaminophen, Celecoxib, 
Gabapentin, Ibuprofen, Lidocaine, Amlodipine, Docusate Sodium, and Levothyroxine provided on March 3, 
2020 and March 4, 2020.  
 
Benefits for the Acetaminophen, Celecoxib, Gabapentin, Ibuprofen, Lidocaine, Amlodipine, Docusate Sodium, 
and Levothyroxine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided on July 31, 2019. 
 
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that Medicare states 
that return trips from a foreign hospital are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services furnished outside the United 
States are excluded. 
 
We looked at the file and Medicare rules. These services were not furnished in the United States. 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 pay for the air ambulance services provided on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or 
heat exchanger (99190) provided on November 26, 2019. 
 
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. 
You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service 
is included in the DRG. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each year?s OPPS/ASC final rule.  
 
 
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
C on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as 
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the 
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger 
(99190) provided on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on January 9, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from August 6, 
2020 forward. 
 
You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient psychiatric services. 
Our reviewer says that the documentation does not support that the requested continued inpatient psychiatric 
services are medically necessary. Our physician reviewer found that you were admitted to the acute inpatient 
psychiatric hospitalization on July 26, 2020 with Major Neurocognitive Disorder with Behavioral Disturbance. 
The documentation does not support that it was expected you would improve in a reasonable period of time for 
the dates in question as you did not have suicidal or homicidal ideation noted and no auditory or visual 
hallucinations. The documentation does not support that the psychiatric care provided at the acute inpatient 
level of care was necessary rather than a lower level of care beyond the dates in question. Therefore, you do not 
meet criteria for the requested continued services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient psychiatric services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient psychiatric services from August 6, 
2020 forward.