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

 
We decided that the Plan does not have to waive the cost share for the wrist brace provided on August 19, 
2020. 
 
You asked the Plan to waive the cost share for the wrist brace. You say that you were never advised that there 
was a copay that would be due. The Plan denied your request. The Plan says the coinsurance was applied per 
your plan 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). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance for the wrist brace. The wrist 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 cost share for the wrist brace 
provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services (G0482) provided on March 12, 
2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the ordering provider's 
progress notes were not submitted. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering 
physician?s intent that the tests be performed. 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 the 
drug testing services (G0482) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 18, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 31, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the medical services provided on February 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (destruction of nerve) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is only documentation of one diagnostic injection being performed. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the LCD requires two separate diagnostic sets of medial branch blocks which produce 80% or greater 
pain relief. There is only evidence of a single set which produced only 70% pain relief. 
 
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 radiofrequency ablation (destruction of nerve) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the item is necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is 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 a Freestyle Libre CGM. Our reviewer 
says that the item is not medically necessary. Our physician reviewer found the enrollee is noted to have type II 
diabetes, for which she takes an oral medication twice a day. How often the enrollee checks her blood glucose 
is not documented. There is no evidence that the enrollee uses the results of blood glucose testing to self-adjust 
insulin dosing multiple times per day. As such, the requested CGM is not shown to be medically necessary or 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch and cane holder wheelchair accessory. 
 
You asked the Plan to pre-approve a crutch and cane holder wheelchair accessory. The Plan denied your 
request. The Plan says that a crutch and cane holder does not meet the definition of DME as it does not serve a 
medical purpose and is a convenience item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a crutch and cane holder wheelchair accessory.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the knee x-ray rendered on September 23, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were told that the services 
would be covered in full after surgery. The Plan denied your request. The Plan says the copayment was applied 
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 $15 
copayment for each in-network Medicare-covered x-ray and ultrasound.  
 
Review of the file shows that you had a knee x-ray on September 23, 2020. X-rays are not included in the 
global surgery package payment. You have been asked to pay a $15 copayment for these services. These 
services fall within the in-network Medicare-covered x-ray and ultrasound benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for the knee x-ray rendered on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services you 
received on August 13, 2020. 
 
You asked the Plan to waive the coinsurance. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 30% 
coinsurance for out-of-network outpatient hospital services.  
 
Review of the file shows that you were provided outpatient hospital services by an out-of-network provider on 
August 13, 2020. The services were allowed at $104.97. You have been asked to pay a 30% coinsurance for the 
services, totaling $31.49. The services fall within the outpatient hospital services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for the outpatient hospital services you received on August 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body for teeth #22 and 27 
(D6010) and semi-precision attachment abutment for teeth #22 and 27 (D6052). 
 
You asked the Plan to pre-approve surgical placement of implant body for teeth #22 and 27 and semi-precision 
attachment abutment for teeth #22 and 27. 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. 
 
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 
surgical placement of implant body for teeth #22 and 27 (D6010) and semi-precision attachment abutment for 
teeth #22 and 27 (D6052).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the annual wellness visit rendered on 
August 8, 2019. 
 
You asked the Plan to waive the coinsurance for these services. You say that the services were an initial 
interview. The Plan denied your request. The Plan says the coinsurance was applied 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 45% 
coinsurance for an out-of-network annual wellness visit.  
 
Review of the file shows that you had an annual wellness visit from an out-of-network provider on August 8, 
2019. You have been asked to pay a 45% coinsurance for these services. These services fall within the out-of-
network annual wellness visit 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 annual 
wellness visit rendered on August 8, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One (J7326). 
 
You asked the Plan to pre-approve Gel-One. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found there is no documentation provided 
indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One (J7326).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the duplex scan you had on August 12, 
2020. 
 
You asked the Plan to adjust the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 $160 
copayment for each Medicare-covered radiological diagnostic service.  
 
Review of the file shows that you had a duplex scan on August 12, 2020. You have been asked to pay a $160 
copayment for the duplex scan. The duplex scan falls within the outpatient diagnostic tests 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 adjust the copayment for the duplex scan you had on August 12, 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 enrollee needs to transfer to a SNF. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate care in the current IRF. 
 
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 documentation does not support that 
skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse 
required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The patient 
does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment. The patient has had 
extensive therapy and education to ensure to safety. The skilled nursing or skilled therapy services (or a 
combination of these services) are not medically necessary on a "daily basis".  As a practical matter, this patient 
does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (S9328) provided. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
this is not a durable medical equipment code and was not delivered to the member's home. The Plan denied 
your request. The Plan says CPT code S9328 is not valid for Medicare purposes. 
 
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 find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9328) 
provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the continuous positive airway pressure 
(CPAP) services rendered from January 10, 2020 to September 10, 2020. 
 
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the cost sharing was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $150 yearly deductible for your covered medical services and 20% of 
the total cost for each Medicare-covered DME item. 
 
Review of the file shows that you received CPAP services from January 10, 2020 to February 28, 2020. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $150 yearly deductible for 
your covered medical services. This cost sharing is a contractual obligation that had not been met at the time 
these services were received on January 10, 2020 to February 28, 2020. The Plan applied the full $150 
deductible to these services. At this time, your yearly deductible had been met. 
 
Given that the $150 deductible did not meet entire the cost of the services, you have also been asked to pay 
20% of the remaining total cost for these services after the deductible has been met. These services fall within 
the Medicare-covered DME item benefit category. This means that you have been asked to pay the correct 
amount for these services based on the contract with the Plan. 
 
Therefore, we decided that the Plan does not have to waive the cost sharing for the continuous positive airway 
pressure (CPAP) services rendered from January 10, 2020 to September 10, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2019. 
 
You asked the Plan to pay for the services provided. You say that the services were due to an emergency. The 
Plan denied your request. The Plan says the claim cannot be adjusted until an explanation of benefits is 
received from the primary insurance. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the services provided until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the medical services provided on April 
16, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 18, 2020, to 
October 20, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the care provided was medically 
necessary. The Plan denied your request. The Plan says that inpatient care was not medically necessary and 
care could have been provided at observational level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee is a 71-year-old male who was brought in by advanced life support ambulance to 
the emergency department on October 15, 2020, for evaluation of low blood sugar at 24 mg/dL associated with 
altered mental status with confusion and combativeness. The review has determined that the record showed that 
at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary 
hospital care (including earlier ED and/or observation care) would span two midnights 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 18, 2020, to October 20, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided on August 7, 2020. 
 
You asked the Plan to pay for the critical care services. You say that the services should have been included in 
the approved inpatient hospital care. The Plan denied your request. The Plan says the services exceed the 
maximum number of units allowed per day. 
 
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 the rules. We find that CPT code 99291 has been billed more than once on the date of 
service at issue. The case file does not include medical records to show that the service at issue were necessary. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the critical care services provided on August 7, 2020.