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

 
We decided that the Plan does not have to pre-approve stance flexion feature additions identified with code 
L5845 and high activity knee control frame additions identified with codes L5930. 
 
You asked the Plan to pre-approve stance flexion feature additions and high activity knee control frame 
additions. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a high activity knee control frame (L5930) is covered 
for enrollees whose functional level is 4. 
 
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 stance flexion feature additions and 
high activity knee control frame additions. Our reviewer says that the documentation does not support that the 
requested items are medically reasonable or necessary. Our physician reviewer found the documentation supports 
that you are a K3 ambulator. You are noted to be very independent, able to dress yourself, and able to 
cook for yourself. The requested high activity knee control frame is only covered for enrollees whose 
functional level is for. This means you do not meet criteria for the requested item. 
 
We looked at this physician's review, the file, and Medicare rules. Review of the file shows that the approved 
knee is Ossur Mauch Knee. The requested codes include L5845. While several Ossur knees use code L5845, 
Mauch Knee is not one of them. L5845 cannot be used for this device and is unbundled. 
 
Based on this information, we decided that Medicare rules for coverage of stance flexion feature additions and 
high activity knee control frame additions have not been met. Therefore, we decided that the Plan does not 
have to pre-approve stance flexion feature additions identified with code L5845 and high activity knee control 
frame additions identified with codes L5930.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided on December 13, 2021. 
 
You asked the Plan to pay for the inpatient admission. You say that services were rendered in good faith and 
payment is expected. The Plan denied your request. The Plan says there is no documented assessment to 
support the enrollee was expected to require a hospital stay over two midnights. 
 
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 the inpatient admission. Our reviewer says 
that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found due to the low complexity of the case and response to initial emergency department 
treatments, it was not expected that the patient would require hospital services that would likely cross 2 
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 the inpatient admission have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient admission provided on December 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Inpatient admission on February 28, 2022, 
March 04, 2022. 
 
You asked the Plan to waive the copayment for Inpatient admission. You say that in your letter you do not 
understand what the bill is for, and you are unable to pay the co-pay. The Plan denied your request. The Plan 
says the cost-sharing you are being charged is correct. 
 
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 $225 
copayment each day for days 1-7 per admission. Includes inpatient acute, inpatient rehabilitation, long-term 
care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are 
formally admitted to the hospital with a doctors order. The day before you are discharged is your last inpatient 
day. There were 4 total days, resulting in a total copayment amount of $900.  
 
You have been asked to pay a $225 copayment for each day of Inpatient admission. Inpatient admission 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 admission on February 28, 2022, March 04, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Glucose monitoring and specialist visit on 
February 10, 2022. 
 
You asked the Plan to waive the copayments for Glucose monitoring and specialist visit. You say that you want 
to appeal the amount being charged. The Plan denied your request. The Plan says the cost-sharing you are 
being charged is correct. 
 
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 $50 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations. Covered services include 
but are not limited to: Laboratory tests. A $20 copayment for office visits to specialists. Covered services 
include: Consultation, diagnosis, and treatment by a specialist. The provider billed in the amount of $30. This is less than the copayment amount. $20 + $30 = $50. Therefore, results in the total cost-sharing amount of $50. 
 
You have been asked to pay a $30 copayment for Glucose monitoring, which is less than the copayment 
amount and a $20 copayment for specialist visit. Glucose monitoring and specialist visit falls within the 
Outpatient diagnostic tests and therapeutic services and supplies and Physician/Practitioner services, including 
doctors office visits 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 copayments for Glucose monitoring 
and specialist visit on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing-four or more teeth 
per quadrant (D4341) and the comprehensive periodontal evaluation (D0180) provided on December 23, 2021 
and January 10, 2022. 
 
You asked the Plan to pay for the dental 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 dental services were received from 
an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the services provided are not covered under this benefit 
when received from an out-of-network provider. Therefore, we decided that the Plan does not have to pay for 
the periodontal scaling and root planing-four or more teeth per quadrant (D4341) and the comprehensive 
periodontal evaluation (D0180) provided on December 23, 2021 and January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 15, 2021. 
 
You asked the Plan to pay for the services provided. You say that using genetics to assist in cancer treatment 
serves as a lifesaving tool. The Plan denied your request. The Plan says one code must be submitted for the 
panel. 
 
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 find that the gene panel was billed with multiple codes. If a single procedure is performed, only one code 
with one unit of service may be reported for the procedure. The medical records provided do not show that the 
services billed with the -XU modifier is a distinct procedural service. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the gene panel testing provided on December 15, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for a sleep study. We decided that the Plan does not 
have to waive the copayment for a sleep study.  
 
You asked the Plan to waive the copayment for a sleep study. You say that this was medically necessary and 
should be covered. The Plan says that the cost-sharing amount you are being charged is correct. 
 
 
 We decided that the Plan has to reduce the copayment for a sleep study.  
 
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 $75 
copayment for sleep studies in any location of service. 
 
The plan says that you must pay $137.72 cost-sharing amount for this sleep study. Based on your contract with 
the Plan, however, you cannot be asked to pay more than $75 copayment for a sleep study. Therefore, we 
decided that the Plan has to reduce the copayment for a sleep study from $137.72 to $75.  
 
We also decided that the Plan does not have to waive the copayment for a sleep study. 
 
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 $75 
cost-sharing amount for a sleep study. Therefore, we decided that the Plan does not have to waive the 
copayment for a sleep study. 
 
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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are requesting do 
not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 document does not support the medical necessity for admission to an IRF. While the enrollee may benefit from continued PT and OT, the enrollee's rehab needs can be safely provided in a 
lower intensity and alternate setting such as in-home with services. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a GYN office visit provided on December 
8, 2021. 
 
You asked the Plan to waive the copayment for a GYN office visit. You say that this should be a routine visit 
and should not have a copayment. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 in-network Physician/Practitioner services.  
 
You have been asked to pay a $35 copayment for a GYN office visit. A GYN office visit falls within the In-
Network Physician/Practitioner Services Physician Specialist Services (Including Surgery Second Opinion, 
Telehealth, and Urgently Needed 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 a GYN office visit provided on December 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided by an out-of-network provider 
from January 4, 2021, through December 22, 2021. 
 
You asked the Plan to pay for acupuncture services. You say that you felt improved after continued 
acupuncture treatments and prescribed herbs from your acupuncture doctor. You say that acupuncture 
treatments are covered, and you are requesting payment. The Plan denied your request. The Plan says you must 
utilize in-network providers that accept Medicare. 
 
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. In addition, the provider does not 
accept Medicare. The Plan did pre-approve acupuncture services but did not pre-approve them with this 
provider. 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 acupuncture services provided by an out-of-network provider 
from January 4, 2021, through December 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that placement of Vertiflex at L3-L5 will not address the pathology at 
the other levels. 
 
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 requested services are not considered medically reasonable and necessary in this case. The vertilfex device 
is experimental. More research is needed. Our physician reviewer found that your condition does not meet 
criteria for coverage of these services. 
 
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 the Vertiflex Superion Interspinous device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient level of care admission for a watchman 
procedure (CPT code 33340). 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has a history of 
coronary artery disease and atrial fibrillation that requires observation after procedure. The Plan denied your 
request. The Plan says the enrollee meets criteria for procedure but do not have any complicated medical issues 
at this time that would require inpatient admission. The Plan states the procedure can be done at hospital under 
observation status. 
 
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 pre-approve 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 review has determined that the record did not show that the admitting 
physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency 
department (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 pre-approve inpatient level of care admission for a watchman procedure (CPT code 33340).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Mammography on January 13, 2022. 
 
You asked the Plan to waive the copayment for Mammography. You say that this was a follow-up visit from 
your annual wellness exam and does not feel a copayment should apply. The Plan denied your request. The 
Plan says the cost-sharing you are being charged is correct. 
 
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 $50 
copayment for Diagnostic Mammography Outpatient Hospital. Covered services include, but are not limited to: 
Other outpatient diagnostic tests. 
 
You have been asked to pay a $50 copayment for Mammography. Mammography 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 waive the 
copayment for Mammography on January 13, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 18, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on January 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic appliance. 
 
You asked the Plan to pre-approve an occlusal orthotic appliance. You say that the appliance being requested is 
intended for the purpose of treating TMJ and is not way related to an oral appliance for sleep apnea. You say 
that you have sought treatment from various providers to relief the pain associated with TMJ. You say that this 
pain includes frequent headaches and daily jaw and face pain, as well as difficulty sleeping. You say that you received extensive testing with specialized equipment designed to analyze muscle activity, jaw movements, and 
confirmed your TMJ pain could be treated with a custom-fitted oral appliance designed to improve jaw 
alignment, reduce stress, and protect teeth hand jaw from excessive clenching and grinding. The Plan denied 
your request. The Plan says the item being requested is not covered for the enrollee's condition. 
 
Medicare generally does not cover oral occlusal appliances used to treat TMJ disorders. The Plan follows the 
same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. The records show that the oral occlusal appliance 
being requested would be to treat TMJ. These are dental services that are not covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic appliance.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient stay provided from May 7, 2021, to May 8, 
2021. 
 
You asked the Plan to pay for the inpatient stay. You say that as the patient was seen in the hospital setting, 
authorization would have been obtained by the hospital, if needed. The Plan denied your request. The Plan says 
the enrollee did not meet the criteria for inpatient status. 
 
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 the inpatient stay. 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 
reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 the inpatient stay have not been met. Therefore, we decided that the Plan does 
not have to pay for the inpatient stay provided from May 7, 2021, to May 8, 2021.