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

 
We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging 
with 4 or more additional parameters of sleep, attended by a technologist (CPT Code 95810). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the service is not medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the service. Our physician reviewer 
found the documentation in the case file does not support that the coverage criteria for Polysomnography; sleep 
staging with four or more additional parameters of sleep, attended by a technologist, for 6 or more hours, are 
met in this case. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters 
of sleep, attended by a technologist (CPT Code 95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment provided on March 10, 2020. 
 
You asked the Plan to pay for the durable medical equipment. 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 state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. 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 the durable medical equipment provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a customized knee brace. 
 
You asked the Plan to pre-approve the custom knee brace. You say that this is medically necessary in order to 
help you be active to help with weight loss so you can qualify for a knee replacement surgery. The Plan denied 
your request. The Plan says the rules for coverage of a custom brace are not met. 
 
The Plan follows Medicare rules. Medicare rules say that custom knee braces may be covered when there is 
documentation to show that a prefabricated brace cannot meet the enrollee's needs.  
 
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 custom knee brace. Our reviewer 
says that the documentation does not support the need for a custom knee brace in this case. Our physician 
reviewer found this enrollee presented with a 6-month history of right knee pain and swelling. Functional 
difficulty was noted due to knee pain. Clinical exam findings have documented joint pain to palpation and 
limited range of motion. X-rays were obtained and showed mild to moderate osteoarthritis, most prominent in 
the medial compartment. The enrollee has a body mass index of 46. A custom-made knee brace was ordered. 
The lower extremity exam did not document a leg or knee deformity, significant thigh/calf discrepancy, 
minimal muscle mass, or any other physical characteristic that would preclude the use of a pre-fabricated knee 
brace. There is no documentation in the available medical records that would support the need of a custom 
fabricated orthosis for this enrollee over a pre-fabricated one for the treatment of her right knee osteoarthritis. 
Therefore, the criteria for the custom-made knee brace is not met in this case. 
 
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 custom knee brace have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a customized knee brace.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation to a medical procedure 120 miles from 
your residence. 
 
You asked the Plan to pre-approve the additional mileage. You say that you need to be seen by a specialist in 
order to have your kidney stone treated and the nearest one is in Cleveland. You have no other options for 
transportation to this appointment. The Plan denied your request. The Plan says your transportation benefit is 
limited to trips up to 75 miles. The additional mileage requested cannot be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers routine transportation when each trip does not exceed 75 miles.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve transportation to a medical procedure 120 miles from your residence.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services (CPT 97167) provided to the 
enrollee on August 5, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the submitted code does not appropriately reflect the services provided by the COTA, as such, 
the appealed service remains denied as not performed. 
 
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 97167 is "Occupational therapy evaluation, high 
complexity, requiring these components: An occupational profile and medical and therapy history, which 
includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or 
psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more 
performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations 
and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an 
analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of 
multiple treatment options. Patient presents with comorbidities that affect occupational performance. 
Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable 
patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or 
family." 
 
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 the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
home visit reports that the visit was performed by COTA. CPT 97167 requires a Licensed Occupational 
Therapist to be present in the home. Documentation submitted does not verify that a Licensed Occupational 
Therapist was in the home during this visit, therefore, this code cannot be verified that the required 
Occupational Therapist was present in the home for this visit. 
 
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 pay for occupational therapy services (CPT 97167) provided to the enrollee on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have continual foot pain and hope  to 
prevent future surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alprazolam tab 0.5mg. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has no Part D pharmacy benefit. 
 
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 Alprazolam tab 0.5mg.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99213) provided on  
March 26, 2020. 
 
You asked the Plan to waive the copayment 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 copayment was applied 
correctly to the service 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $40 copayment per visit to a specialist.  
 
The enrollee has been asked to pay a $38 copayment for the specialist office visit provided. This amount is the 
Plan allowed amount which is less than the applicable copayment. This means that the enrollee has been asked 
to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the 
enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the office visit (99213) provided on March 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit with an out of network provider. 
 
You asked the Plan to pre-approve a second opinion with an out of network specialist. You say that you would 
like a second opinion from the out of network specialist. The Plan denied your request. The Plan says you have 
been referred to another doctor in the 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the office 
visit with an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on June 2, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not authorized. 
 
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 nursing facility care (99308) provided on June 
2, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for a Freestyle Libre continuous glucose 
monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that you've had the CGM for over a year and it 
makes things more manageable. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM and supplies are covered 
when specific criteria are 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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you 
have diabetes that is well-controlled with a single injection of insulin. Given this information, you do not meet 
the criteria for coverage of the CGM and sensor. The services are therefore not reasonable or medically 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sensors for a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further for the dental services rendered on February 19, 2020. 
 
You asked the Plan to pay further for these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the claim was processed correctly. 
 
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 supplemental 
dental benefits with a $1,000 annual maximum.  
 
We looked at the file and Medicare rules. The file shows that the Plan paid for the services up to the $1,000 
annual maximum. Further payment is not covered by Medicare or your supplemental dental benefit. Therefore, 
we decided that the Plan does not have to pay further for the dental services rendered on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays, addition to existing partial 
denture, and extraction of erupted tooth rendered on May 7, 2020 to May 11, 2020. 
 
You asked the Plan to pay for these services. You say that you had an infection and needed emergency care. 
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 pay for the 
intraoral periapical x-rays, addition to existing partial denture, and extraction of erupted tooth rendered on May 
7, 2020 to May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit and self-administered drugs 
provided on December 15, 2019. 
 
You asked the Plan to pay for emergency care and self-administered drugs. You say that you are on a fixed 
income and do not feel you owe this amount. The Plan denied your request. The Plan says the copayment 
amount you are being charged is correct. The Plan also says that the denial of payment for self-administered 
drugs is correct because these drugs are not covered by Medicare Part B. 
 
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 $90 
copayment for emergency room visit. The rules also 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. 
 
You have been asked to pay $90 copayment for emergency care. Emergency care 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 pay for an emergency room visit and self-administered 
drugs provided on December 15, 2019.  
 
Benefits for self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from
March 21, 2020 to March 31, 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 were not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on
March 4, 2020 after hospitalization for encephalopathy and pneumonia. He received oral medications and had
stable vital signs. He was treated for lower extremity edema with diuretics. He received physical, occupational,
and speech therapy in the SNF and, by the dates in question, was at a modified independent level with
functional mobility, including gait to 100 feet with a cane. He was modified independent for activities of daily
living. He had no daily skilled nursing or daily skilled therapy needs. As a practical matter, the enrollee did not
require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) services rendered from March 21, 2020 to March 31, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 13, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit for the evaluation and management of an 
established patient (99335). You say that your physician did provide the service and deserves to be reimbursed. 
The Plan denied your request. The Plan says prior authorization was not requested. 
 
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 services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the physician services provided on January 13, 2020 by an out of network 
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76641 provided on January 15, 
2020. 
 
You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 76641 is ultrasound, breast, unilateral, real time with 
image documentation, including axilla when performed; complete. 
 
We find that CPT code 76641 is not supported in the medical record. Specifically, the documentation submitted 
does not indicate that ultrasound, breast, unilateral, real time with image documentation, including axilla when 
performed; complete was performed bilaterally on the billed date of service. Based on this information, we 
decided that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultrasound services coded 76641 provided on January 15, 2020.