Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is 
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an 
acute inpatient rehabilitation facility admission. 
 
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status 
does not currently require intensive physician and nursing oversight only in an inpatient rehabilitation facility. 
You may benefit from multiple therapies such as physical and occupational therapy but the documentation does 
not support that your functional status requires an intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. 
 
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for transitional care management services (99496) provided 
October 24, 2019. 
 
You asked the Plan to pay for transitional care management services. You say that since the enrollee was in a 
nursing facility, the doctor was not responsible to get authorization. The nursing home is responsible to obtain 
prior authorization. Kindly review and reprocess the claim. The Plan denied your request. The Plan says CPT 
definition of code 99496 and place of service 11 are not supported 
 
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 99496 is , transitional care management services. 
 
We find that CPT code 99496 is not supported in the medical record. Specifically, transitional care 
management services are reported for patients requiring moderate to high complex medical decision making 
who are transitioning from an inpatient facility to a home or community type setting, such as a domiciliary or 
assisted living facility. The provider originally billed two codes for DOS 10/24/2019: CPT 99306 and 99496. 
Both codes were originally billed with place of service 32 for nursing facility, but the doctor rebilled with place 
of service 32 for CPT 99306 and place of service 11 (office) for CPT 99496. Place of service 11 is not 
supported. Based on this information, we decided that Medicare rules for coverage of transitional care 
management services have not been met. Therefore, we decided that the Plan does not have to pay for 
transitional care management services (99496) provided October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on March 31, 2020. 
 
You asked the Plan to pay for the back brace. You say that this was a medically necessary brace. The Plan 
denied your request. The Plan says there is no evidence that the ordering physician was prescribing a back 
brace for this patient. 
 
The Plan follows Medicare rules. Medicare rules say that a back brace may be covered when the above noted 
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 pay for the back brace. Our reviewer says that the 
documentation does not support the medical necessity of the requested brace. Our physician reviewer found 
there is no documentation that support the medical necessity for the spinal orthosis. Although the history 
portion of the office visit note mentions the back brace and a discussion of the risks and benefits of the device, 
there is nothing in the note documenting that the brace is being ordered for one of the covered indications listed 
in the LCD. 
 
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 back brace have not been met. Therefore, we decided that the Plan does not 
have to pay for the back brace provided on March 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the infusion services you received at an 
outpatient hospital facility from April 14, 2020 through April 23, 2020. 
 
You asked the Plan to waive the copayments for the infusion services. You say that if you had stayed an 
inpatient, your costs would have been significantly lower.  You also say that this was a life-saving treatment 
that should be covered. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $375 
copayment for outpatient hospital services.  
 
Records show that you went to the outpatient hospital facility twice per day for ten days for these infusion 
services.  The Medicare-allowed rate for each service was $177.76.  According to your Evidence of Coverage, 
you are responsible for a copayment of $375 for each outpatient hospital service.  Because the allowed amount 
is less than your copayment, you were only assessed the allowed amount.  Since you had 20 of these services, 
you owe a total of $3555.20 (20 x $177.76 = $3555.20). 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. Although your costs may have been less if you were an inpatient, the fact 
remains that you had these services on an outpatient basis. Therefore, we decided that the Plan does not have to 
waive the copayments for the infusion services you received at an outpatient hospital facility from April 14, 
2020 through April 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve access to the Plan's Special Supplemental Benefits for 
the Chronically Ill. 
 
You asked the Plan to pre-approve Special Supplemental Benefits for the Chronically Ill. You say that you 
need these benefits because you have high blood pressure. The Plan denied your request. The Plan says you do 
not qualify for these benefits. 
 
Medicare rules say that MA Plans can offer supplemental benefits for items or services not covered by original 
Medicare. The Plan offers such a benefit for supplemental services for chronically ill enrollees. To qualify for 
these benefits you must have one of the conditions listed above. 
 
We looked at the file and Medicare rules. The information submitted by your doctor indicates that you do not 
have any of the conditions listed above. High blood pressure is not a qualifying condition for this benefit. 
Based on this information, we decided that Medicare rules for coverage of Special Supplemental Benefits for 
the Chronically Ill have not been met. Therefore, we decided that the Plan does not have to pre-approve access 
to the Plan's Special Supplemental Benefits for the Chronically Ill.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) screening. 
 
You asked the Plan to pre-approve a LDCT screening. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested LDCT 
screening. 
 
The Plan must follow Medicare rules. Medicare rules say that LDCT is covered if all of the above criteria are 
met.  
 
We looked at the file and Medicare rules. The review shows that you do not meet the Medicare criteria 
requirement of being between the ages of 55 and 77 years. The file shows that you are going on 79 years old. 
Based on this information, we decided that Medicare rules for coverage of a LDCT screening have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography 
(LDCT) screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the clinical crown lengthening (D4249). 
 
You asked the Plan to pre-approve the clinical crown lengthening (D4249). You say that the tissue is very 
inflamed with deep margins around #7. You say that the crown lengthening is the best recommended treatment. 
The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
clinical crown lengthening (D4249).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Gel One knee injections. 
 
You asked the Plan to pre-approve the Gel One injection. You say that the enrollee has tried physical therapy in 
the past and this was not helpful. The Plan denied your request. The Plan says that the record does not show 
that a recent trial of PT was failed or actual objective information about her condition. 
 
The Plan follows Medicare rules. Medicare rules say that hyaluronan injections for the knee may be covered 
when the criteria noted above 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 the Gel One injection. Our reviewer 
says that the requested treatment is shown to be medically reasonable and necessary based on the 
documentation. Our physician reviewer found this enrollee presents with complaints of bilateral knee pain, 
right greater than left. Functional limitations are noted in activities of daily living. Clinical exam findings have 
been consistent with reported radiographic of severe, bone-on-bone, right knee medial compartment 
osteoarthritis, and moderate left knee medial compartment osteoarthritis. Conservative treatment has included 
physical therapy, home exercise program, medications, and cortisone injections. She reports decreasing benefit 
with cortisone injections with relief limited to 2 weeks.  
 
Under consideration is a request for Gel-One injections to both knees. Medicare coverage criteria have been 
met. There is evidence of bilateral knee moderate to severe medial compartment osteoarthritis. Pain interferes 
with functional mobility. Clinical exam findings support radiographic findings. She has failed long-term 
conservative treatment, including reduced benefit to cortisone injections. Therefore, this request for Gel-One 
injections is medically reasonable and 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 Gel One injection have been met. Therefore, we decided that the Plan has to 
pre-approve Gel One knee injections.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for the services from February 19, 2020 through 
February 28, 2020. 
 
You asked the Plan to waive the cost-share for the services. You say that this should be covered because you 
have Covid-19. The Plan denied your request. The Plan says the claims were processed accordingly with your 
2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ambulance services on February 19, 2020. You are asked to pay a 
$250 copayment for the ambulance services. Furthermore, you received inpatient hospital care from February 
20, 2020 through February 23, 2020. Your EOC states that enrollees must pay a $225 copayment per day for 
days 1-8 and a $113 copayment for days 9. Your cost-share for this admission is less than the $675 copayment 
and you are asked to pay $487.12 for this inpatient stay.  
 
Review of the file shows that you were admitted on February 23, 2020 and discharged on February 28, 2020. 
You were asked to pay a $225 copayment per day from February 23, 2020 through February 27, 2020, days 1-5 
of your inpatient hospital care. You were discharged on February 28, 2020 and there was no copayment charge 
for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-5. 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 cost-share for the services from February 19, 2020 through February 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer System device. 
 
You asked the Plan to pre-approve the Superion Interspinous Spacer System device. You say that the requested 
Superion Interspinous Spacer System device is medically necessary. The Plan denied your request. The Plan 
says the requested Superion Interspinous Spacer System device is not medically 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 Superion Interspinous Spacer 
System device. Our reviewer says that the requested Superion Interspinous Spacer System device is not 
medically necessary. Our physician reviewer found the enrollee is with a history of chronic lower back pain for 
decades with recent worsening. The Superion device is experimental. More research is needed to show safety 
and efficacy. It is not medically needed in this case. There is no documented spinal instability. 
 
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 Interspinous Spacer System device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Superion Interspinous Spacer System device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PPE provided on May 26, 2020. 
 
You asked the Plan to pay for PPE. You say that you thought the cleaning would be free because your wife was 
told there would be no charge. You also say that neither you nor your wife were informed that you would be 
charged for the personal protective equipment. The Plan denied your request. The Plan says this service is not 
covered under the supplemental benefit. The Plan also says that you signed a financial agreement claiming 
financial responsibility for services not covered by your insurance 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 PPE 
provided on May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital stays from February 7, 
2020 to March 4, 2020. 
 
You asked the Plan to waive the copayments for inpatient hospital stays. You say that you disagree with the 
charges because the enrollee passed away and cannot afford the charges. The Plan denied your request. The 
Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $320 copayment for days 1-5 for inpatient hospital care.  
 
The enrollee had an inpatient hospital stay from February 7, 2020 to February 14, 2020. Therefore, the enrollee 
is responsible to pay a $320 copayment for days 1-5 (February 7, 2020 to February 11, 2020). $320 
(copayment) x 5 (inpatient days) = $1,600.  
 
The enrollee had an inpatient hospital stay from February 26, 2020 to March 1, 2020. Therefore, the enrollee is 
responsible to pay a $320 copayment for days 1-5 (February 26, 2020 to March 1, 2020). $320 (copayment) x 5 
(inpatient days) = $1,600. 
 
The total amount the enrollee owes is: $3,200.  
 
The enrollee has been asked to pay the total copayment amount of $3,200 for inpatient hospital stays. Inpatient 
hospital stays fall within the inpatient hospital care benefit category. 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 copayments for inpatient hospital stays from February 7, 2020 to March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter and a crutch and cane holder. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says group 2 power vehicles have added items that are not needed for use in the home. 
 
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 patients 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 it is not clear that 
your mobility deficit impairs participation in MRADLs in the hone. You were given crutches in October 2019; 
therefore, it is not clear why you cannot resolve your mobility deficit with the crutches. There is no detailed 
neuromuscular exam by a treating practitioner in the records. The documentation reveals that you had a home 
survey, but the documentation is vague on whether the specific scooter can fit in the home. The survery does 
not note a visual inspection of the home to be able to see if the scooter can be safely maneuvered. The 
requested crutch and cane holder are convenience items and  per per Social Security Act, Section 1862 (a)1(A) 
and the 42 CFR ?411.15(k), are not reasonable and necessary for the diagnosis or treatment of illness or injury 
or to improve the functioning of a malformed body member. 
 
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 power scooter and a crutch and cane holder.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on March 17, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered 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 services at issue in this appeal. The Plan did not pre-approve the services 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 laboratory services rendered by the out of network (OON) provider on March 17, 
2020.