Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections (64636x3) provided on May 2, 2020. 
 
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not 
support the number of units billed. 
 
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 64636x3 is destruction by neurolytic agent, paravertebral 
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint 
(List separately in addition to code for primary procedure). 
 
We asked our coder 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 facet joint injections. Our reviewer says that CPT code 
64636x3 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical 
records provided do not include sufficient documentation to corroborate a destruction by neurolytic agent, 
paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional 
facet joint was performed on May 2, 2020. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pay for facet joint injections (64636x3) provided on May 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric scooter and lift chair. 
 
You asked the Plan to pre-approve an electric scooter and lift chair. You say that you have been kept from 
going on with your regular life without the proper equipment to move. The Plan denied your request. The Plan 
says the records show this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The submitted medical records state that the item at issue in this appeal is for use outside of the home. 
Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. 
Therefore, we decided that the Plan does not have to pre-approve an electric scooter and lift chair.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the maxillary partial denture. We decided that the Plan does not 
have to pay for the porcelain fused to metal retainer crowns and porcelain fused to metal pontic crown.  
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you are entitled to coverage for 
dental services. The Plan says that these services are not covered under your benefit plan. 
 
We decided that the Plan has to pre-approve the maxillary partial denture.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has denied the request for the maxillary partial denture based on 
medical necessity and citing your dental records. However, the Plan has not forwarded the medical records 
used to make this decision. Therefore, we decided that the Plan has to pre-approve the maxillary partial denture 
(D5213). 
 
We also decided that the Plan does not have to pay for the porcelain fused to metal retainer crowns and 
porcelain fused to metal pontic crown. 
 
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 
porcelain fused to metal retainer crowns (D6751) and porcelain fused to metal pontic crown (D6241) provided 
on August 24, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 additional direct skilled nursing services of a RN in 
the home health or hospice setting. 
 
You asked the Plan to pre-approve the additional direct skilled nursing services. The Plan denied your request. 
The Plan says two home health skilled nursing visits were approved, but further home health skilled nursing 
visits need to be determined after initial evaluation. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional direct skilled nursing 
services. Our reviewer says that additional direct skilled nursing services are not medically reasonable and 
necessary. Our physician reviewer found the documentation does not support that you require additional skilled 
nursing visits to provide medically necessary treatment. The Health Plan has authorized 2 visits and based on 
the results of these visits, further need for additional home health can be made. Our reviewer also found that 
you have been medically stable without any recent medication changes, hospitalizations, or urgent care visits. 
 
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 direct skilled nursing services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 3 additional direct skilled nursing services of a RN in the 
home health or hospice setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flex Foot system for a prosthesis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Flex Foot system with 
multi-axial rotation unit is not the standard of care for the enrollee's condition. There is no objective clinical 
documentation in the enrollee's treating medical practitioner notes that support that the enrollee is at least a K3 
functional level or has the potential to be given his medical comorbidities, history of not being ambulatory for 
some time, and without support in the treating medical practitioner progress notes. The services are therefore 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Flex Foot system for a prosthesis.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating provider on May 28, 2020, to June 25, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayment 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 $40 
copayment for outpatient rehabilitation services/in-network/physical therapy/outpatient hospital.  
 
You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked 
to pay is $280 ($40 x 7 visits = $280). Physical therapy falls within the outpatient rehabilitation services/in-
network/physical therapy/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 physical therapy provided by a participating provider on May 28, 2020, to June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of intra-socket biological dressing to aid in 
homeostastis or clot stab (D7922) teeth # 11 and 12. 
 
You asked the Plan to pre-approve the dental services. You say that you have been waiting to have 3 teeth 
pulled. You say that these teeth have sharp edges which are causing bleeding on your tongue and pain. You 
also say that you cannot afford to pay out of pocket for this service. The Plan denied your request. The Plan 
says placement of intra-socket biological dressing to aid in homeostastis or clot stab is not listed as a covered 
service. 
 
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. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve placement of intra-socket 
biological dressing to aid in homeostastis or clot stab (D7922) teeth # 11 and 12.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to provide Xgeva (J0897). 
 
You asked the Plan to provide Xgeva (J0897). You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says the health plan states the drug is not being requested for a medically 
accepted indication. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 provide Xgeva (J0897). Our reviewer says that the 
drug is not reasonable and medically necessary. Our physician reviewer found Xgeva is not indicated in the 
management of this patient. It would not be considered standard of care for the management of hypercalcemia 
in this patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Xgeva (J0897) have not been met. Therefore, we decided that the Plan does not 
have to provide Xgeva (J0897).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $90 copayment for emergency room services provided on 
July 16, 2020. 
 
You asked the Plan to waive this service. You say that you do not believe this copayment is correct. The Plan 
denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $90 
copayment for emergency room services. 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 $90 copayment for emergency room 
services provided on July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 9, 2020, through 
July 13, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that the enrollee's care could have been provided at an 
observational level of care. 
 
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 it was reasonable to expect that two or more midnights would be necessary for the hospital stay.  
Given underlying health conditions, medical history and need for interventions in the past; the patient was at 
high risk for complication. 
 
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. Specifically, it was reasonable to 
believe the enrollee's care would span at least two midnights. Therefore, we decided that the Plan has to pay 
for the acute inpatient hospital care provided from July 9, 2020, through July 13, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on September 14, 
2020. 
 
You asked the Plan to waive the copayment for the CT scan. 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 a CT scan on the date of service at issue in this appeal. The Plan says 
that the correct copayment 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 $150 
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress 
tests). 
 
We looked at the file the, the Plan's contract and Medicare rules. The file shows that you received a CT scan on 
September 14, 2020. You have been asked to pay a $107.79 copayment for the CT scan, which is less than the 
contracted $150 copayment amount. The CT 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 waive the copayment for the CT scan provided on September 14, 2020.  
 
Your complaint about receiving the incorrect information from the Plan is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 patient'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 respiratory failure and pneumonia. Medical conditions are stable. There are no medical needs 
requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While the medical record documents a need for physical and 
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a 
reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $5 copayment for physician services provided on August 
6, 2020. 
 
You asked the Plan to waive this copayment. You say that this was a routine physical and should be no charge. 
The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the 
provider and the Plan contract agreement. This was not billed as an annual physical by the physician.  
 
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 $5 
copayment for physician visits. 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 $5 copayment for physician services provided on August 6, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ultrasound rendered on February 24, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that the provider told you that you only 
owed a $20 copayment. 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 $200 
copayment per visit for any diagnostic test or special procedure that is provided in an outpatient or ambulatory 
surgical center or in a hospital operating room.  
 
Review of the file shows that you received an ultrasound at an outpatient hospital facility on February 24, 
2020. You have been asked to pay a $200 copayment for these services. These services fall within the any 
diagnostic test or special procedure that is provided in an outpatient or ambulatory surgical center or in a 
hospital operating room 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 
ultrasound rendered on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided on January 31, 2020, through 
February 10, 2020. 
 
You asked the Plan to pay for inpatient care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient care. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee did not appear to require 
inpatient mental health treatment as he was not a danger to himself or others and was cooperative and 
compliant. Active treatment was not taking place and it did not appear that the services were reasonably 
expected to improve the patient's condition or for the purpose of diagnosis. The admission  of this patient does 
not meet the criteria for acute inpatient mental health treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Specifically, it was not reasonable or 
necessary to place the enrollee in an inpatient level of care. Therefore, we decided that the Plan does not have 
to pay for inpatient care provided on January 31, 2020, through February 10, 2020.