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

We decided that the Plan has to pre-approve MyoPro G orthotic device (myoelectric elbow-wrist-hand-finger 
orthosis)(CPT Code L8702). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says that the use of this orthosis is unproven or experimental or investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 device. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found evidence based studies have demonstrated improvement in function and significant motor gains 
in those individuals utilizing myoelectric upper limb orthosis. Given that this enrollee has failed traditional 
physical therapy to improve the function of their right arm, it would be medically acceptable to implement a 
myoelectric upper limb orthosis to assist with improved functionability. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve MyoPro G orthotic device (myoelectric elbow-wrist-hand-finger orthosis)(CPT Code L8702).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) provided on 
July 13, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the chiropractic manipulative treatment. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 chiropractic manipulative treatment (98940) 
provided on July 13, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 Mg Invokana tablets. 
 
You asked the Plan to pre-approve the Invokana. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for your condition 
under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 100 Mg Invokana tablets.  
 
Benefits for the Invokana may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated safely at a SNF level of care. 
 
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 enrollee's nursing, medical and rehabilitation needs do not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require an 
intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level appears to be more 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the CT scan of the head provided on 
June 8, 2020 billed with code 70450-26. 
 
You asked the Plan to pay for the CT scan interpretation. You say that these services were provided and should 
be paid. The Plan denied your request. The Plan says payment cannot be made for this Column 2 code as no 
appropriate modifier was billed to bypass the edit. 
 
The Plan must follow Medicare rules. Medicare rules say that if two codes from a PTP edit pair are reported by 
the same provider on the same date of service, payment can only be made for the Column 2 code if a modifier 
is reported.  
 
In this case, CPT code 70450 is a Column 2 code in relation to code 70496, which was billed by the same 
provider and paid for this date of service. No clinically appropriate modifier was used on 70450 to justify 
bypassing the edit. Therefore, we decided that the Plan does not have to pay for the interpretation of the CT 
scan of the head provided on June 8, 2020 billed with code 70450-26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Accu-Chek Aviva test strips. 
 
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied 
your request. The Plan says there must be a medical reason for using a non-preferred product. 
 
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 test strips. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided there is no documentation to support any specific 
medical necessity for the Accu-Chek Aviva test strips. There is nothing in the provided records to indicate the 
Ascensia Contour brand meter and test strips would be inadequate for the enrollee's 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 test strips have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Accu-Chek Aviva test strips.
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 does not require skilled nursing 
and/or skilled therapy services on a daily basis. The enrollee's physical function is at or near his baseline and he 
can receive services at a lower level of care. 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the 20% coinsurance charged for a penicillin injection 
provided on June 30, 2020. 
 
You asked the Plan to waive this coinsurance. You say that you do not believe this cost share is correct. The 
Plan denied your request. The Plan says this cost share was charged based on the services provided and the 
Plan contract agreement. 
 
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 Medicare Part B drugs. 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 20% coinsurance charged for a penicillin 
injection provided on June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lower limb prostheses (L5986, L5999). 
 
You asked the Plan to pay for the durable medical equipment. You say that these parts are required. The Plan 
denied your request. The Plan says that some of the requested protheses were overturned, but the L5986 and 
L5999 remain denied because they are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that  
 
There is a request for L5999, heavy duty end skeletal components due to weight. This is unbundled from the 
base codes used to build the prosthesis. All components and fabrication are covered by the base codes that are 
already approved. The description does not include any mention of multi-axial capability, and the manufacturer 
uses only L5976 to build this foot. The requested L5986 exceeds the member's needs and cannot be approved. 
Therefore, we decided that the Plan does not have to pay for the lower limb prostheses (L5986, L5999).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from May 
17, 2020 to June 10, 2020. 
 
You asked the Plan to pay for SNF. You say that the SNF care provided was necessary. The Plan denied your 
request. The Plan says rules for SNF care have 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 pay for SNF. Our reviewer says that daily skilled 
services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs 
and no identifiable skilled therapy service needs. Furthermore, the beneficiary does not require skilled nursing 
or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for 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 have not been met. Therefore, we decided that the Plan does not have to 
pay for the skilled nursing facility (SNF) stay provided from May 17, 2020 to June 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health services, or home with outpatient therapy. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
repair of a broken hip after a fall. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. You do 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 you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve audiology services to be provided by requested 
provider. 
 
You asked the Plan to pre-approve the audiology services. The Plan denied your request. The Plan says in order 
to receive care outside the primary network, the care needs to be emergent or if out of area, care may be urgent 
as well. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve audiology 
services to be provided by the requested provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services rendered on July 7, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 Medicare-covered lab services in an outpatient hospital.  
 
Review of the file shows that you received laboratory services on July 7, 2020. You have been asked to pay a 
$15 copayment for these services. These services fall within the Medicare-covered lab services in an outpatient 
hospital 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 laboratory services 
rendered on July 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided. 
 
You asked the Plan to pay for the outpatient surgery. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
outpatient surgery. 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 outpatient surgery provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a polysomnography provided on January 7, 2020. 
 
You asked the Plan to pay for the polysomnography. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
polysomnography. 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 a polysomnography provided on January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight extractions to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that your teeth are bad, and you need to have them 
pulled. The Plan denied your request. The Plan says dental services are only covered when rendered by a 
participating general dentist. The Plan also says that dental services by an oral surgeon are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are provided by anyone other than a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve eight extractions to be provided by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria has not been met. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an office visit to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on August 3, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were told that it would 
be covered 100%. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
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 outpatient surgery.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $6,583.12. The total amount you are being asked to pay is $1,316.62 ($6,583.12 x 20% = 
$1,316.62). An outpatient surgery falls within the outpatient surgery 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 an outpatient surgery provided by a participating provider on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ophthalmology services provided on 
November 8, 2019. 
 
You asked the Plan to waive the copayment for the ophthalmology services. You say that it was a preventative 
exam so you should not have a copayment. The Plan denied your request. The Plan says you were charged the 
copayment correctly however they will reduce your copayment to $5. 
 
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 $40 
copayment.  
 
You have been asked to pay a $40 copayment for the ophthalmology services. Based on the diagnosis code 
billed by your provider this service would traditionally have a copayment of $40. The Plan has reduced the 
copayment to $5. 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 ophthalmology services 
provided on November 8, 2019.