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

 
We decided that the Plan does not have to pre-approve durable medical equipment and related supplies to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the services were specifically requested to 
increase compliance and efficacy of treatment. The Plan denied your request. The Plan says the enrollee's plan 
has network providers who are able to provide the requested services. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
durable medical equipment and related supplies to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth service provided on May 7, 2020, by an out-of-network provider.
You asked the Plan to pay for the telehealth service. You say that authorization should not be needed under
telemedicine. The Plan denied your request. The Plan says you did not request 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 has network providers
available who can provide the services at issue in this appeal. 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 the telehealth service provided on May 7, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from 
December 8, 2020 and forward. 
 
You asked the Plan to pre-approve the continuation of inpatient mental health care from December 8, 2020 and 
forward. You say that the continuation of inpatient mental health care from 12/8/20 and forward is medically 
necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from 
12/8/20 and forward is 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 pre-approve the continuation of inpatient mental 
health care from December 8, 2020 and forward. Our reviewer says that the continuation of inpatient mental 
health care from 12/8/20 and forward is not medically necessary. Our physician reviewer found based upon 
review of the records provided, the enrollee does not meet the criteria for continued acute inpatient mental 
health treatment for the dates in question of December 8, 2020 forward as this enrollee was not shown to be a 
danger to herself or others. She was not showing any auditory or visual hallucinations and was 
cooperative/compliant with 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 the continuation of inpatient mental health care from December 8, 2020 and 
forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation 
of inpatient mental health care from December 8, 2020 and forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjunctive procedure and extraction provided on June 11, 
2020. 
 
You asked the Plan to pay for the adjunctive procedure and extraction. You say that you do not know why this 
claim was denied. The Plan denied your request. The Plan says the adjunctive procedure is excluded from 
coverage. The Plan also says that you have already been reimbursed the maximum dental allowance of $850. 
 
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, unspecified adjunctive procedure is not 
among those covered under this benefit. The Plan contract also clearly states that the Plan offers an $850 
annual dental allowance. The contract says that you are responsible for any amount above the dental coverage 
limit. The record shows that you met the annual maximum benefit while processing this claim for the June 11, 
2020 date of service, and your annual maximum benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the adjunctive procedure and extraction provided on June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 17, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you only received a shot, not a 
surgical procedure, and disagree with the charges. 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 $490 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You received arthrocentesis on June 17, 2020, at an outpatient hospital facility. Arthrocentesis is considered an 
outpatient surgical procedure. Therefore, you are responsible to pay the $490 copayment.  
 
You have been asked to pay a $490 copayment for arthrocentesis. Arthrocentesis falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the L3-L5 Vertiflex device for the enrollee. 
 
You asked the Plan to pay for the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not yet the standard of care as supported by the medical literature and current 
guidelines for the management of spinal stenosis. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the device 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 pay for the L3-L5 Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory services provided on June 12, 
2020. 
 
You asked the Plan to waive the cost share for laboratory services. The Plan denied your request. The Plan says 
the cost share 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 your combined in-network and out-of-network medical deductible is $250. This 
is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. 
Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your 
contract with the Plan also says that you must pay 20% coinsurance for Medicare-covered lab services from an 
in-network or out-of-network provider.  
 
The item or service you asked the Plan to waive the cost share for falls within the "Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that your $250 deductible applies to outpatient diagnostic tests. This cost sharing is a 
contractual obligation that had not been met at the time the laboratory services were received on June 12, 2020. 
Therefore, $202.48 has been applied to meet your deductible. 
  
 
 
Since your $250 deductible was met, you have also been asked to pay $130.88, which is 20% of the allowed 
amount for the laboratory services. The allowed amount is $654.40 (654.40 x 20% = $130.88). 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 laboratory services provided on June 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that your current 
denture is deteriorated, and cannot be relined or repaired. You also say that you cannot afford to pay for the 
dentures. The Plan denied your request. The Plan says these services are not a covered benefit under your plan. 
 
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 a 
maxillary partial denture and a mandibular partial denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The 
Plan denied your request. The Plan says your request for approval of admission to a LTACH does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a chronic left ankle ulcer for which he has been receiving home 
wound care. The treating nurse has requested admission to LTACH for further wound care.  
 
This enrollee does not meet criteria for LTACH admission. He has not had a recent acute inpatient stay for his 
left ankle ulcer and does not have evidence of acute infection documented by an MD that would require 
intravenous antibiotics. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided by a participating 
provider on September 1, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that this was your annual physical. 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 $10 
copayment for physician/practitioner services/in-network/PCP.  
 
You have been asked to pay a $10 copayment for an office visit. When additional services are provided that go 
beyond an annual wellness exam, additional copayments can be applied; therefore, the correct copayment has 
been applied. An office visit falls within the physician/practitioner services/in-network/PCP 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 an office visit provided by a participating provider on 
September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve full-length bed side rails for the enrollee. 
 
You asked the Plan to pre-approve the rails. You say that this is medically necessary. The Plan denied your 
request. The Plan says these are only covered as part of a covered hospital bed. 
 
The Plan must follow Medicare rules. Medicare rules say that bed side rails are covered when they are required 
by the beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed. 
 
While full-length bed side rails may be appropriate in this case, neither the Plan nor Medicare offers coverage 
for this item, as a total electric hospital bed was previously requested and statutorily denied. Therefore, we 
decided that the Plan does not have to pre-approve full-length bed side rails for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan coded 70450 provided on June 18, 2020.
You asked the Plan to pay for the CT scan. 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, we have confirmed that code 70450
for the CT scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be
paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the CT scan coded 70450 provided on June 18,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for podiatry services provided on March 5, 
2020. 
 
You asked the Plan to waive the copayment for podiatry services. You say that you feel that the charges are 
fraudulent. 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 $35 
copayment for podiatry services.  
 
The medical records show that you received podiatry services on March 5, 2020. Therefore, you are 
responsible to pay the $35 copayment.  
 
You have been asked to pay a $35 copayment for podiatry services. Podiatry services falls within the podiatry 
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 podiatry services provided 
on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 25, 2020, by a non-
network provider. 
 
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 the services were rendered by a non-network provider without 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 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 medical services provided on June 25, 2020, 
by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81404, 81405, 81479, 81408). 
 
You asked the Plan to pre-approve the genetic testing. You say that you have a family history of cancer and 
therefore the genetic testing is medically necessary. The Plan denied your request. The Plan says coverage 
criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met.  
 
We looked at the file and Medicare rules. Insufficient medical records were provided to support the medical 
necessity of the requested genetic testing. Records provided were limited to a note from a physician. The plan 
requested additional clinical documentation but none was provided. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (81404, 81405, 81479, 81408).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional PT visits. 
 
You asked the Plan to pre-approve the additional PT visits. You say that the additional visits are medically 
necessary. The Plan denied your request. The Plan says there is nothing in the supplied documentation that the 
condition of the enrollee will be such that the services required can be safely and effectively performed only by 
a qualified therapist or under a therapist's supervision versus HEP after the total approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as 
specific and effective therapy for the enrollees condition. The enrollee has had extensive therapy for this 
condition, and it does not appear that the enrollee's functional level requires the unique skills of a professional 
therapist to safely and effectively provide treatment, or that the services can be safely and effectively 
performed only by a therapist, or under the supervision of a therapist. Our reviewer also found that the enrollee 
has been authorized additional sessions to review an independent exercise program. The specialized skill, 
knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to 
maintain the enrollee's current condition or to prevent or slow further deterioration. 
 
 
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 PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 8 additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a frenulectomy (D7960). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under the member's 
contractual policy. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
frenulectomy (D7960).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide a continuous glucose monitor. 
 
You asked the Plan to provide a continuous glucose monitor. You say that a CGM would be beneficial for A1C 
lowering and better controlled Diabetes. The Plan denied your request. The Plan says the enrollee is not 
performing testing four times a day or getting three or more insulin injections daily. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Therefore, we 
decided that the Plan does not have to provide a continuous glucose monitor.