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

 
We decided that the Plan does not have to pay for orthotic items provided on February 11, 2020. 
 
You asked the Plan to pay for orthotic items. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these items is correct, because the delivery ticket 
submitted did not include the carrier's tracking number, nor did the proof of delivery include details to 
corroborate the delivery ticket submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information 
to the Plan to determine whether payment is due for a claim. The rules also say that the information submitted 
by the supplier must corroborate the medical documentation and confirm that coverage criteria have been met. 
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof that the 
specific items billed on this claim were delivered to the enrollee. The Plan requested additional records from 
you to support valid delivery of the items billed but this information was not provided. Without this 
information, you have not furnished sufficient information to the Plan to justify payment of the claim. Based on 
this information, we decided that Medicare rules for coverage of orthotic items have not been met. Therefore, 
we decided that the Plan does not have to pay for orthotic items provided on February 11, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you 
received on June 12, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that when you went to the ER, the 
physician there said that since there was nothing he could do for you, that you wouldn't have to pay for 
anything. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 
copayment for emergency care.  
 
You have been asked to pay a total of $95.74 ER services. The total allowable amount for this ER visit was less 
than the $120 copayment required in your Evidence of Coverage for ER services, which is why you were 
charged the full allowable amount. In addition, we looked at your medical records for these ER services and 
there is nothing in these records to indicate you were advised that no cost sharing would apply. 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 emergency room (ER) services you received on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two extractions, a maxillary partial denture, and a 
mandibular partial denture. 
 
You asked the Plan to pre-approve the extractions, maxillary partial denture, and mandibular partial denture. 
You say that you are in extreme pain and believe you still have an infection, which you were prescribed 
medicine for. The Plan denied your request. The Plan says your plan does not cover these procedures. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
extractions, a maxillary partial denture, and a mandibular partial denture.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography (CT) scan of the Heart with 
Calcium Scoring (75571). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says coverage criteria is not met. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 and Medicare rules. The plan made multiple requests to obtain medical records to support 
the request. No medical records have been provided for review. Based on this information, we decided that 
Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography (CT) scan of the Heart with Calcium Scoring (75571).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital services you had from 
November 30, 2019-December 3, 2019 and the skilled nursing facility (SNF) services you received from 
December 3, 2019 through December 31, 2019. 
 
You asked the Plan to waive the copayments for the inpatient hospital services and the SNF services. You say 
that you only wanted to stay in the SNF for as long as you had a $0 copayment.  You also stated that you were 
not happy with the SNF and that they lied to you about the cost of certain services. The Plan denied your 
request. The Plan says you were charged these copayments correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment per day for days 1-5 for Medicare-covered hospital care as well as $0 for days 1-20 and $150 per 
day for days 21-100 in a skilled nursing facility. 
 
In this case, you were in an inpatient hospital facility for three days (not including the date of discharge). 
(Please note that you were not double charged for the date of December 3, 2019.)  The Plan charged you a $300 
copayment per day for each of these days, for a total of $900.  You were then transferred to a SNF.  In 
accordance with your Evidence of Coverage, you were not charged a copayment for the first 20 days of this 
stay.  For the remaining 7 days of your SNF stay, you were charged a daily copayment of $150, for a total of 
$1,050. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayments for inpatient hospital services you had from 
November 30, 2019-December 3, 2019 and the skilled nursing facility (SNF) services you received from 
December 3, 2019 through December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling (D4346). 
 
You asked the Plan to pre-approve periodontal scaling. You say that the service is medically necessary. The 
Plan denied your request. The Plan says Coverage for periodontal scaling and root planing is limited to dental 
codes D4341 and D4342. 
 
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 
periodontal scaling (D4346).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture for neck pain. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this can only be approved for low back pain treatment. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, these services are not being requested for low back 
pain. Neck pain is not a covered indication. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture for neck pain.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the upper extremity joint for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no plain x-ray conducted in the evaluation of the enrollee's underlying 
complaint. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the telemedicine visit of 
7/23/20 did not include a physical exam or x-rays.  The clinical impression is "impingement" and no red flags 
are apparent although no physical exam occurred. No plain films have been done. There is no plan for 6 week 
trial of PT. Absent these items medical necessity for the requested MRI has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the upper extremity joint for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 medically reasonable or necessary. Our physician reviewer found in this case, the 
enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, or a standard 
manual wheelchair). The current equipment used is a four wheeled walker. Therefore, this request is not 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transport trips (W6110). 
 
You asked the Plan to pre-approve the additional routine transport trips. You say that the trips are medically 
necessary to get blood work and injection treatments. The Plan denied your request. The Plan says your routine 
transport benefit has been exhausted. 
 
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 a maximum of 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transport trips (W6110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second medial branch block for the enrollee. 
 
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your 
request. The Plan says a second confirmatory block is allowed if the documentation indicates the first medial 
branch block produced more than 80% relief of primary pain. 
 
The Plan must follow Medicare rules. The rules say that a second confirmatory medial branch block is allowed 
if the documentation indicates the first medial branch block produced more than 80% relief of primary pain,  
 
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 block. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the standard for a positive diagnostic MBB test is 80% pain relief.  This was not achieved. 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 block have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a second medial branch block for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of a Superion interspinous decompression 
device. 
 
You asked the Plan to pre-approve the Superion device procedure. You say that this procedure should be 
allowed due to medical necessity. The Plan denied your request. The Plan says there is a lack of medical 
evidence showing that this procedure is as or more effective than standard surgery. 
 
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 Superion device procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found this enrollee presents with complaints of worsening grade 5-6/10 low back pain. 
Signs/symptoms are reported consistent with intermittent neurogenic claudicatio n. Pain and symptoms interfere 
with quality of life and activities of daily living. He has reportedly failed conservative treatment, including 
physical therapy, medications, spinal injections, and activity modification.  
 
Under consideration is a request for Vertiflex Superion procedure for L4/5. Current evidence based medical 
guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 
gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome 
studies to support the use of this device for this enrollee's medical condition as discussed above. There is no 
discussion relative to why this enrollee would not be indicated for standard decompression surgery. 
Additionally, there is no MRI report submitted for review. The requesting physician documented multilevel 
degenerative disease but there is no discussion of moderate spinal stenosis at the L4/5 level and no evidence 
that spinal stenosis is limited to 2 levels from L1-L5. Superion indirect lumbar decompression would not be 
considered the standard of care for the enrollee's medical condition. Therefore, this request for Superion 
indirect lumbar decompression is not reasonable and medically necessary for this enrollee's medical condition. 
 
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 Superion device procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve placement of a Superion interspinous decompression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this will give you a better quality of life. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 10, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for medical supplies. You say that the Plan is required to pay for these items if they 
were referred by an in-network provider. The Plan denied your request. The Plan says the denial of payment for 
these items is correct, because this provider is out-of-network with the Plan and the referring provider is also 
out-of-network with 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 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 January 10, 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 foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you have bad pain in your foot and cannot walk 
well without the inserts. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493). 
 
You asked the Plan to pre-approve facet joint injections. You say that your doctor recommended this treatment. 
The Plan denied your request. The Plan says you have not had conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that for facet joint injections to be covered, the 
patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain 
is inadequately responsive to conservative care. 
 
We looked at the file and Medicare rules. The medical records do not support that you have had conservative 
care such as NSAIDs, acetaminophen, or physical therapy. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections (64493).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a waterproof leg prosthesis. 
 
You asked the Plan to pre-approve the prosthesis. You say that this is needed for aquatic physical therapy. The 
Plan denied your request. The Plan says you have an operating prosthetic at this time, and aquatic therapy is not 
a long term service. 
 
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 prosthesis. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this is a convenience item and not supported above traditional measures/prostheses. Aquatic 
therapy is also not indicated above traditional land therapy. As such, this request is not 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 the prosthesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a waterproof leg prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Optometry services provided on March 17, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the Optometry services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services received were neither emergent 
nor urgent and prior authorization was not obtained to seek out-of-network care. The Plan says there are 
equally qualified in-network Optometrist's available to you that could have provided the care and treatment you 
received. 
 
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 Optometry services provided on March 17, 
2020 by an out of network (OON) provider.