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

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve the repairs. You say that this is medically necessary. The Plan denied your 
request. The Plan says a lightweight folding custom manual wheelchair is recommended instead. 
 
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 repairs. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you have diabetes mellitus with neuropathy with functional deficits. You are able to use a lightweight 
manual wheelchair in the home and community. The documentation does not support that you require repairs. 
 
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 repairs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve power wheelchair repairs.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve temporomandibular joint arthroscopy 
 
You asked the Plan to pre-approve temporomandibular joint arthroscopy. You say that you would like to appeal 
because you cannot eat and is losing weight. Your doctor stated that there is nothing else that will help without 
this treatment. The Plan denied your request. The Plan says that the records do not support that the enrollee 
meets the medically necessary criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
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 temporomandibular joint arthroscopy. 
Our reviewer says that the requested items/services is considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was seen 9/2021 for pain in the left TMJ which resulted from a 
trauma 8 months prior. The arthroscopy of the TMJ meets the criteria for coverage of medically reasonable and 
necessary since the condition is medical in nature and not dental. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of temporomandibular joint arthroscopy have been met. Therefore, we decided 
that the Plan has to pre-approve temporomandibular joint arthroscopy  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the records do not show the need for continued treatments. 
 
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 was admitted with abdominal pain and underwent surgery for a bowel 
obstruction. The record indicates that the enrollee is improving but requires ongoing acute care services. The 
enrollee continues to receive acute care services and these have not been denied. The medical record does not 
indicate that the enrollee requires services that she is not currently receiving but that would be available at the 
LTACH facility. The elements of the coverage rules are not satisfied/ 
 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephonic evaluation of a pacemaker provided on 
October 8, 2021, by an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the telephonic evaluation of a pacemaker. You say that the enrollee was unable 
to seek the correct primary care physician to sign their orders, and the service was medically necessary. The 
Plan denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the telephonic evaluation of a pacemaker provided on October 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient admission to a right stemless total shoulder 
arthroplasty, and right tenodesis of long tendon of biceps. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to 
undergo this elective procedure. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the record does not show that at the time of inpatient admission, the admitting 
physician reasonable expected that the patients necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. Detailed documentation is not evident regarding a significant past 
and/or current medical history that would place this enrollee at increased risk for peri-surgical complications 
requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception to guidelines. Therefore, the record does not show 
that at the time of inpatient admission, the admitting physician reasonable expected that the patients necessary 
hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient admission to a right stemless total shoulder arthroplasty, and right 
tenodesis of long tendon of biceps.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and 
management of an established patient (99334) and the nail debridement (11721) rendered by the out-of-
network (OON) provider on September 20, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 domiciliary or rest home visit for the evaluation and management of an 
established patient (99334) and the nail debridement (11721) rendered by the out-of-network (OON) provider 
on September 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan of the extracranial arteries; 
complete bilateral study (93880) provided on July 9, 2021. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $155 
copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility.  
 You have been asked to pay a $155 copayment for the Medicare-covered radiological diagnostic service 
provided. 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 duplex scan of the extracranial arteries; 
complete bilateral study (93880) provided on July 9, 2021.
Appeal type: Surgery
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 there is extensive disease proximal and distal to the levels where the procedure is 
planned. 
 
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 this device is experimental. More research is 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 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve lumbar medial branch block injections. 
 
You asked the Plan to pre-approve lumbar medial branch block injections. You say that lumbar medial branch 
block injections are medically necessary. The Plan denied your request. The Plan says that the member does 
not meet medical necessity requirements for the lumbar medial branch block injections because the member 
had no consistent pain relief of a minimum of 80% sustained relief after previous lumbar MBBs. 
 
The Plan follows Medicare rules.  
 
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 lumbar medial branch block injections. 
Our reviewer says that lumbar medial branch block injections are medically necessary. Our physician reviewer 
found that the enrollee clearly meets the Medicare LCD criteria. The request is deemed medically reasonable 
and 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 lumbar medial branch block injections have not been met. Therefore, we 
decided that the Plan has to pre-approve lumbar medial branch block injections.  
 
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 psychiatric diagnostic evaluation provided on December 
3, 2021, by an out-of-network (OON) provider. 
 
 
 You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the provider relies on the 
facility staff to verify eligibility and obtain authorization form the enrollee's insurance company. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on December 3, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a debridement of open wound (97598) and additional 
supplies, material, and clinical staff time (99072) provided on July 7, 2021. 
 
You asked the Plan to pay for a debridement of open wound and additional supplies, material, and clinical staff 
time. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. 
The Plan says rules for payment have not been 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. 
 
In this case, we have confirmed that code 97598 is an add-on code and has not been billed with an appropriate 
primary procedure code. Per the Physician Fee Schedule, CPT code 99072 has a status indicator of B. This 
means that the payment for 99072 is always bundled into the payment for another service or procedure. Based 
on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does 
not have to pay for a debridement of open wound (97598) and additional supplies, material, and clinical staff 
time (99072) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for wound repair, the removal of skin growth, 
and a dermatology specialist office visit provided on May 4, 2021. 
 
You asked the Plan to waive the cost share for surgical services and a specialist office visit. You say that the 
doctor did not ask you if you wanted to check with your insurance before doing the procedure, so you assumed 
it was covered. You also say that you feel there should be an adjustment or waiver of the balance due to the fact 
you were not aware of the charge beforehand. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible which applies to outpatient surgery at an outpatient hospital. The Plan contact also says that an enrollee must pay a $35 copayment for a specialist office visit. The 
contract says if you receive other services during the office visit, the deductible, and other cost sharing may 
apply according to that benefit specific category. 
 
The surgical services you asked the Plan to waive the cost share for falls within the Outpatient Surgery, 
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 
deductible which applies to outpatient surgery at an outpatient hospital. This cost sharing is a contractual 
obligation that had not been met at the time surgical services and a specialist office visit was received on May 
4, 2021.  
 
You have also been asked to pay a $35 copayment for a specialist office visit. A specialist office visit falls 
within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have been 
asked to pay a total of $434.31 ($97.56 towards deductible + $301.75 towards deductible + $35 copayment = 
$434.31). 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 wound repair, the removal of skin growth, and a 
dermatology specialist office visit provided on May 4, 2021.  
 
Your complaint about receiving the bill six months later and not being told of the charges before the procedure 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70544 billed for date of service December 3, 
2021. 
 You asked the Plan to pay for procedure code 70544. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70544 is bundled into payment for 
code 70553 
 
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 70544 
is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70544 billed for date of service December 3, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a computed tomography (CT) scan of the 
abdomen and pelvis provided on November 5, 2021. 
 You asked the Plan to reduce the coinsurance for a CT scan. You say that you were traveling and needed to 
have cancer treatment at an in-network facility. You also say that you expected to only pay 20% of the allowed 
charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 40% 
coinsurance for out-of-network advanced imaging services, including CT scans. The Plan contract also says 
that services will be covered if you are using an out-of-network provider for emergency care, urgently needed 
services, or out-of-area dialysis and you may not have to pay a higher cost-sharing amount. The Plan contract 
also says that urgently needed services are non-emergency, unforeseen medical illness, injury, or condition that 
requires immediate medical care.   
 
The Plan confirmed that the provider is out-of-network. The record does not show your care was an emergency 
or unforeseen urgently needed services. You have been asked to pay $35.24, which is 40% of the allowed 
amount for a CT scan ($88.10 allowed amount x 40% coinsurance = $35.24). A CT scan falls within the 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the coinsurance for a computed tomography (CT) scan of the abdomen and pelvis provided on 
November 5, 2021.