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

We decided that the Plan does not have to pre-approvean electric scooter.You asked the Plan to pre-approvean electric scooter. You say that the enrollee has a history of knee osteoarthritis and uses a walker.The Plan denied your request. The Plan says the face to face evaluation and supporting medical information indicate that the enrollee has sufficient upper extremity function to operate and propel a manual wheelchair.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 an electric scooter. Our physician reviewer found the requested power mobility device is not medically necessary. The documentation does not reveal that the enrollee has a personalmobility deficit that impairs participation in MRADLs in the home. The enrollee'smobility deficit is currently helped by a walker and there is no indication the enrollee cannot use a manual wheelchair. The documentation reveals the enrollee has the cognition to safely operate a PMD but there is no in person assessment in the enrollee's home to evaluate that they can safely maneuver the PMD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electric scooter have not been met.Therefore, we decided that the Plan does not have to pre-approvean electric scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
January 11, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the Plan told you that if 
you were admitted as inpatient there would be no copayment. The Plan denied your request. The Plan says 
there is no record of you contacting the Plan and 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 $310 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $310 for these 
services. 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 ambulance services provided on January 11, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional stellate ganglion blocks. 
 
You asked the Plan to pay for the additional stellate ganglion blocks. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says repeat 
blocks are not supported when the number of shots exceeds the allowed limit. 
 
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 pay for the additional stellate ganglion blocks. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested procedure exceeds utilization limits and is not evidence 
based. There are evidence-based therapies available. 
 
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 additional stellate ganglion blocks have not been met. Therefore, we 
decided that the Plan does not have to pay for additional stellate ganglion blocks.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's clinical condition meets the full acute 
inpatient rehabilitation criteria. You say that a lower level of care cannot provide the total interdisciplinary 
team approach needed. The Plan denied your request. The Plan says the guidelines for coverage have not been 
met. The Plan says that the records do not show that an intensive team is needed for the enrollee's care. The 
Plan says that the enrollee can safely receive the services needed in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for abscess of the groin. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. The medical record supports a need for physical and occupational 
therapy, but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
 
 
therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections provided from February 12, 
2020 to February 13, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you feel you should not be 
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you received Part B injections on the dates of service at issue in this appeal. The 
Plan says the correct coinsurance has applied per your contract with the Plan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received injections on 
February 12, 2020 and February 13, 2020. You have been asked to pay a 20% coinsurance for the injections, 
totaling $251.62. The injections fall within the Medicare Part B prescription drugs benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the injections provided from February 12, 2020 to February 13, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on May 8, 2020. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not medically necessary to treat the enrollee's condition or to improve medical outcomes. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this test is FDA-approved for patients with non-small cell lung cancer, melanoma, colorectal cancer, 
ovarian cancer, or breast cancer to help identify the most effective treatments. This type of genetic testing has 
not yet been clearly shown to lead to superior outcomes compared to not testing to help support this request. 
Therefore, this request for this assay will be considered not medically necessary at this time. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided to the enrollee on May 8, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital. She does not require skilled nursing and/or skilled therapy services on a 
daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although 
further rehab services would be appropriate to improve function, as a practical matter, the daily skilled services 
can be provided at a lower level of care than a skilled nursing facility. Admission to a SNF for inpatient skilled 
rehab services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by you on May 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device. 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says the device is not 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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to leading 
authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage 
criteria are not met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the heart computed tomography provided 
on June 18, 2020. 
 
You asked the Plan to waive the copayment for the heart computed tomography (CT). You say that you were 
told the procedure was covered with no charge. 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 $300 
copayment for outpatient diagnostic tests, CT.  
 
You have been asked to pay a $300 copayment for the heart computed tomography (CT). The heart computed 
tomography (CT) falls within the outpatient diagnostic tests, CT benefit category. The billed charge was less 
than $300, so your copayment was calculated to be $99.03. 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 heart computed tomography provided on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 18, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the testing is not a 
Medicare benefit for diagnosis listed on the claim. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
There are insufficient medical records to show that the test results will be used to determine a specific 
diagnosis or treatment strategy. The testing at issue in this appeal was requested for screening purposes. 
Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have 
to pay for the lab services provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the subsequent hospital care, per day (99233) rendered by the out-of-
network (OON) provider on June 2, 2019. 
 
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 that a determination was not made within the 
60 day time frame; therefore, the case file was forwarded to the independent review entity for a decision. 
 
The Plan must follow Medicare rules. Medicare rules say that PPOs must furnish all services in-network and 
out-of-network, but may charge higher cost-sharing for plan covered services obtained out-of-network.   
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have been met. Additionally, the Plan contract states that enrollees may receive 
services rendered by in-network and out-of-network providers. Services rendered by an out-of-network 
provider do not require a referral or prior authorization. Therefore, we decided that the Plan has to pay for the 
subsequent hospital care, per day (99233) rendered by the out-of-network (OON) provider on June 2, 2019.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic services (77061) provided on June 12, 2020. 
 
You asked the Plan to pay for the diagnostic services (77061). 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. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, CPT code 77061 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Based on this information, we decided that 
Medicare rules for coverage of the diagnostic services (77061) have not been met. Therefore, we decided that 
the Plan does not have to pay for the diagnostic services (77061) provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the full body jacket back brace (L0464) 
provided on November 11, 2019. 
 
You asked the Plan to waive the coinsurance for the full body jacket back brace. You say that you would like 
reconsideration because the provider said this equipment would be covered by the Plan. The Plan denied your 
request. The Plan says your cost-share has been assessed 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 20% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay $231.48. The allowed amount for this equipment is $1,157.40. 20% of $1,157.4 is 
$231.48. You have been asked to pay the correct amount. 
 
You have been asked to pay 20% coinsurance for the full body jacket back brace. This back brace falls within 
the Durable Medical Equipment benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the full body jacket back brace (L0464) provided on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue regeneration (D4265) for tooth # 18 provided on 
November 19, 2019. 
 
You asked the Plan to pay for the dental service. You say that you were advised that there would be no 
copayment for this service. You also say that you cannot move forward with your treatment until your balance 
is paid. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
We 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 dental service. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found biologic materials to regenerate soft and 
osseous tissue is normally utilized when trying to retain a tooth with bone loss. The reviewer found that this 
was not the case. The reviewer also found that the documentation provided does not support the criteria for 
coverage for the use of biologic materials to regenerate soft and osseous tissue. 
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pay for the tissue regeneration (D4265) for tooth # 18 provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the refractive testing provided on June 22, 
2020. 
 
You asked the Plan to waive the charges for the refractive testing. You say that you paid $15 up front for this 
visit and were never told that the refractive testing would not be covered. You feel that you have been 
defrauded. The Plan denied your request. The Plan says your coverage only applies to medical eye exams. 
Refractive testing is not a covered medical eye test and is excluded from coverage under Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover refractive testing, regardless 
of the diagnosis for which it is provided. Therefore, we decided that the Plan does not have to waive the 
charges for the refractive testing provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim upper complete denture, implant body placements 
and extractions provided on April 17, 2019, April 25, 2019, and May 22, 2019. 
 
You asked the Plan to pay for the interim upper complete denture, implant body placements and extractions. 
You say that other providers could not perform the work. You say that you are requesting reimbursement. The 
Plan denied your request. The Plan says out-of-network dental services are not covered benefits. 
 
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, out-of-network dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
interim upper complete denture, implant body placements and extractions provided on April 17, 2019, April 25, 
2019, and May 22, 2019.