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

We decided that the Plan does not have to pre-approve a knee orthosis (L1845). 
 
You asked the Plan to pre-approve the orthosis. You say that you have tried an over-the-counter brace and it 
has not worked. The Plan denied your request. The Plan says the records do not demonstrate recent injury or 
surgery. 
 
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 orthosis. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence of recent injury to or a surgical procedure on the left knee. The documentation does 
not reveal instability on an objective physical exam of the left knee. The physician progress note indicates a 
negative valgus and varus stress test at 0 and 30 degrees of flexion as well as negative anterior and posterior 
drawer tests. The documentation does not indicate the criteria per the Local Coverage Determination (LCD): 
Knee Orthoses (L33318) have been met. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1845).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve negative pressure wound therapy (wound VAC). 
 
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 wound VAC therapy is covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a leg wound. Recent 
notes show that the wound worsened with past use of the wound VAC, suggesting no benefit. Without prior 
benefit, the criteria for wound VAC therapy are not met and the services are 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 negative pressure wound therapy (wound VAC).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc, which don't require 
prior authorization. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The documentation does not outline contraindications or reasons these 
medications were not considered. Without the support of the documentation, Euflexxa is not approved as step 
criteria is not met. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy (PT) and occupational 
therapy (OT) services provided February 14, 2020 to February 19, 2020. 
 
You asked the Plan to waive the copayment for the PT and OT services. You say that you was to be discharged 
from the facility but was found to need physical therapy and you're being charged $20 copay for each date of 
service. You never left the facility and should not be charged. The Plan denied your request. The Plan says this 
claim was processed and the correct copayment was applied per the Evidence of Coverage 
 
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 
copayment per provider, per date of service for Outpatient rehabilitation services.  
 
You have been asked to pay $120 copayment for the PT and OT services. The PT and OT services falls within 
the Outpatient rehabilitation 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 copayment for 
the physical therapy (PT) and occupational therapy (OT) services provided February 14, 2020 to February 19, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
August 17, 2020, to August 20, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are being charged a 
separate copayment because you were moved to the intensive care unit. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 
copayment for days 1-5 for inpatient hospital care.  
 
The medical records show that you received inpatient hospital care from August 17, 2020, to August 20, 2020. 
Therefore, you are responsible to pay a $310 copayment for days 1-3 (August 17, 2020, to August 19, 2020). 
The total amount you owe is: $310 (copayment) x 3 (inpatient days) = $930.   
 
You have been asked to pay the total copayment amount of $930 for inpatient hospital care. Inpatient hospital 
care falls within the inpatient hospital care 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 inpatient hospital care provided from August 17, 2020, to August 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on June 21, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
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 June 21, 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 on June 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper dentures. 
 
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 request exceeds the benefit limit. 
 
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 a complete 
upper denture once every five plan years.  
 
We looked at the file and the Plans rules. You are requesting a new complete upper denture. The file shows 
that you received a complete upper denture on July 22, 2019 for which the Plan approved and paid. You are not 
eligible for another complete upper denture until five years have passed from that date. Therefore, we decided 
that the Plan does not have to pre-approve complete upper dentures.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy (PT) services rendered from June 29, 
2020 to July 31, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 97110, 97112, and 97530 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The 
definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular 
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting 
and/or standing activities. The definition of code 97530 is therapeutic activities, direct (one-on-one) patient 
contact (use of dynamic activities to improve functional performance), each 15 minutes. 
 
We find that CPT codes 97110, 97112, and 97530 are  not supported in the medical record. Specifically, these 
are time-based codes and the records do not document the time spent on the enrollee for each code. 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 pay for the physical therapy (PT) services rendered from June 29, 
2020 to July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services coded as CPT 99217 and CPT 99220 
provided too he enrollee from November 15, 2019, to November 17, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
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 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 this service. Our reviewer says that Medicare billing criteria are not met. Our physician 
reviewer found the same provider/group billed the same codes on a previous claim. Per NCCI Edits these codes 
cannot be billed by the same provider/group on the same date of service and a modifier is not allowed to enable 
the billing of these 2 codes together.  Also, per NCCI Edits these codes cannot be billed by the same 
provider/group on the same date of service and a modifier is not allowed to enable the billing of these 2 codes 
together. We looked at this physician's review, the file, and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan 
does not have to pay for physician services coded as CPT 99217 and CPT 99220 provided too he enrollee from 
November 15, 2019, to November 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the out of network dental office visit 
provided on September 22, 2020. 
 
You asked the Plan to waive the copayment for the dental visit. You say that you were aware that the provider 
was out of network. You also say that you were not advised there would be an out of network copayment. The 
Plan denied your request. The Plan says the provider in this case is out of network. The Plan says there is a $40 
copayment for dental office visits that you receive out of network. 
 
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, there is a $40 copayment for dental 
office visits that you receive out of network. This is a contractual obligation you agreed to when you enrolled 
in the Plans dental coverage. Therefore, we decided that the Plan does not have to waive the copayment for the 
out of network dental office visit provided on September 22, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on  
August 20, 2019. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation with medical services. The Plan denied 
your request. The Plan says the Plan requires utilization of network providers when possible and available, and 
requires authorization for certain services. No medical necessity for an out-of-network provider, such as an 
urgent or emergency situation, has been documented.   
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a psychiatric diagnostic evaluation with medical services 
provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins services provided on 
August 24, 2020. 
 
You asked the Plan to pay for the duplex scan of extremity veins services. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 93971 is duplex scan of extremity veins including 
responses to compression and other maneuvers; unilateral or limited study. 
 
We find that CPT code 93971 is not supported in the medical record. Specifically, the documentation supports 
one unit of this code, which was previously approved/paid. There is no additional documentation supporting an 
additional study, which was billed. Based on this information, we decided that Medicare rules for coverage of 
the duplex scan of extremity veins services have not been met. Therefore, we decided that the Plan does not 
have to pay for the duplex scan of extremity veins services provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion Vertiflex Interspinous Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device 
is medically necessary. The Plan denied your request. The Plan says this device is experimental. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental and more research is needed to determine its safety and efficacy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion Vertiflex Interspinous Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says a review of the current medical literature shows that this is considered experimental and 
investigational. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says no operative management such as PT or NSAIDs is documented. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the criteria for a lumbar 
MRI is not met. More conservative measures for back pain, such as physical therapy, are needed. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 2, 
2019. 
 
You asked the Plan to pay for the hospital outpatient clinic visit. You say that you did not know this provider 
was out-of-network and you were not notified by the provider that your insurance plan was out-of-network. 
The Plan denied your request. The Plan says services provided by non-participating providers are excluded 
from coverage. 
 
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 
hospital outpatient clinic visit. 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 hospital outpatient clinic visit provided on 
December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer. 
 
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 enrollee has a history of back pain. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. 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 Vertiflex Superion spacer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self administered drugs received on August 7, 2020 and 
August 8, 2020. 
 
You asked the Plan to pay for the drugs. You say that this was necessary due to the surgery that was performed. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 pay for self administered drugs received 
on August 7, 2020 and August 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core buildup, including pins when required (D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that these services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says these services are not covered under your benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup, including pins when required (D2950).