Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation goals that include 
returning closely to their prior level of function. You say that admission to IRF is required as the enrollee's 
current needs cannot be safely met at a lower level of care. The Plan denied your request. The Plan says based 
on Medicare guidelines and the information we have about your condition you do not meet the requirements. 
 
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 enrollee was admitted for endocarditis and aortic valve surgery. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the enrollee has a need for 
physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 the IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for custom shoe molds provided on March 
14, 2022. 
 
You asked the Plan to reduce the coinsurance for the shoe molds. You say that you feel you were billed for two 
sets and received only one. The Plan denied your request. The Plan says the correct coinsurance was 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 20% 
coinsurance for diabetic shoes and inserts. 
 
You have been asked to pay $25.57, which is 20% of the allowed amount for each of the shoe molds ($127.85 
allowed amount x 20% coinsurance = $25.57). The total for both shoe molds is $51.14. The shoe molds falls 
within the Diabetes Self-Management Training, Diabetic 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 custom shoe molds provided on March 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine transport trip (A0170). 
 
You asked the Plan to pre-approve the routine transport trip. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the request exceeds the allowed benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when a one-way trip is less than 75 miles. 
 
We looked at your request, the records in the case file, and the rules. The destination is 115 miles. This exceeds 
the allowable limit of 75 miles per one-way trip. Based on this information, we decided that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve a routine transport trip (A0170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro represents this enrollees best 
opportunity for regaining meaningful use for his left upper limb and has been deemed medically necessary for 
this enrollee by his provider. The Plan denied your request. The Plan says this item is considered experimental 
and investigational. There is insufficient evidence of its effectiveness. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair cover and rear basket. 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says this does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 
This item is available to the general public and would be helpful even to those who are not sick or injured. 
Therefore, we decided that the Plan does not have to pre-approve the wheelchair cover and rear basket.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for inpatient hospital care provided from April 
5, 2022, to April 7, 2022. 
 
You asked the Plan to reduce the copayment for the inpatient care. You say that you were only supposed to stay 
for 1 day. You say that the added day is too much. 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 $475 per 
day for days 1-4 and $0 per day after day 4 for each inpatient admission.  
 
The file shows that you were in the hospital from April 5, 2022, to April 7, 2022. Since there is no copayment 
for the discharge date, you have been asked to pay $475 per day for days 1-2 of inpatient care. The total for 
your stay is $950 ($475 copayment x 2 days = $950). The inpatient 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 reduce the copayment for inpatient hospital care provided 
from April 5, 2022, to April 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on March 17, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you feel you should have been 
better informed about this charge. The Plan denied your request. The Plan says the coinsurance charged 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this item is $5.70 resulting in a 
coinsurance amount of $1.14 ($5.70 x 20% = $1.14). 
 
 
 
 
 
 
 You have been asked to pay a $1.14 coinsurance for an injection. An injection falls within the Medicare Part B 
Prescription Drugs 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 coinsurance for an injection 
provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dental services on March 14, 2022. 
 
You asked the Plan to waive the coinsurance for dental services. You say that you were unaware that your 
dental provider was no longer participating with your plan, you state he was in network all of 2021. 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% 
coinsurance for non-Medicare covered preventive dental services and 50% coinsurance for non-Medicare 
covered comprehensive dental services. The provider billed in the amount of $60 and the Plan paid $30. $60 - 
$30 = $30.00. The provider also billed in the amount of $101 and the Plan paid $50.50. $101 - $50.50 = 
$50.50. The provider also billed in the amount of $54 and the Plan paid $27. $54 - $27 = $27.00. $30 + $50.50 
+ $27 = $107.50. Therefore, results in the total cost sharing amount of $107.50. 
 
 
 You have been asked to pay a 50% coinsurance for dental services. Dental services fall within the Dental 
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 coinsurance for dental services on March 
14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery coded 
with procedure codes 22869 and 22870. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that you strongly believe that coverage should 
be provided. The enrollee is a candidate for a Vertiflex. The Plan denied your request. The Plan says this 
procedure is considered experimental and investigational. There are not enough studies to show that use of the 
Vertiflex Superion device will help in the enrollee's care. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the Vertiflex Superion device placement surgery coded with procedure codes 22869 and 22870.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #20 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that food sticks in this area which could cause periodontal 
problems in the future if not corrected. The Plan denied your request. The Plan says that there is no evidence of 
decay or a missing crown to support the need for a replacement. 
 
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 Plan covers a crown when 
the services are medically necessary and reasonable. 
 
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 a crown. Our reviewer says that the 
coverage criteria has been met. Our physician reviewer found that a review of the documentation indicates the 
presence of a defective crown on tooth #20. In this case, it is medically reasonable and necessary to place a 
replacement crown to correct this situation and prevent further problems such as caries and periodontal issues. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have been met. Therefore, we decided that the Plan has to pre-approve 
a crown on tooth #20 (D2740).  
 
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: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown for tooth #11. We decided that the Plan does not have to 
pre-approve a crown for tooth #8.  
 
You asked the Plan to pre-approve a crown for teeth #8, and #11. You say that these crowns are medically 
necessary because you are having a lot of sensitivity. The Plan says that the medical criteria for D2740 has not 
been met.  
We decided that the Plan has to pre-approve a crown for tooth #11.  
 
Our doctor found that tooth #11 does appear to have a mesial defect at the margin however and would need 
replacement. Therefore, we decided that the Plan has to pre-approve a crown for tooth #11.  
 
We also decided that the Plan does not have to pre-approve a crown for tooth #8. 
 
Our doctor found that there would not be a clear need for replacement of the old crowns on #8, certainly not for 
the provided rationale that then teeth are sensitive to stimuli, where there are no nerves in the teeth. Therefore, 
we decided that the Plan does not have to pre-approve a crown for tooth #8. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D2740 - tooth #3, 30, 31, D2950 - tooth 
#3, 4, 31 D3330 - tooth #3, 31). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says for the services to be approved, the teeth must be in good periodontal health, and have 
good bone support. 
 
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 the services 
when the services are medically necessary and reasonable.  
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that the provided 
x-rays reveal that teeth #3 and 31 have significant bone loss on the distal roots of each tooth, in excess of 50% 
of supporting structures. The long term prognosis of a tooth with significant bone loss is much poorer than when 
there is greater than 50% remaining bone. The decision to treat a compromised tooth with endodontic 
therapy includes an assessment of the long term stability of the tooth so as not to treat a tooth that has a  limited 
prognosis.  Tooth #4 has almost no missing structure, and would not be in need of a core buildup for a 
crown.  The tooth, following endodontic therapy, would be restored with a conventional restoration and coded 
for such a restoration, and not a core buildup as requested. As teeth #3 and #31 are compromised and would not 
be considered for endodontic treatment due to the periodontal condition, the subsequent treatment of crown 
restorations also would not be considered as the teeth have poor long term prognoses. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental services (D2740 - tooth #3, 30, 31, D2950 - tooth #3, 4, 31 D3330 - tooth #3, 31).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that facet joint injections are medically 
necessary. The Plan denied your request. The Plan says facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
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 facet joint injections. Our reviewer says 
that facet joint injections are not medically necessary. Our physician reviewer found in this case, there was no 
documentation of a consistent positive response of at least 80% relief of primary (index) pain (with the duration 
of relief being consistent with the agent used) after the first diagnostic facet procedure. The review has 
determined that the requested medial branch blocks/facet joint injections do not meet the Medicare LCD 
coverage criteria. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on October 22, 
2021, by an OON provider. 
 
You asked the Plan to pay for a psychiatric diagnostic evaluation. You say to please reprocess the claim as it 
was medically necessary. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 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 had network providers 
available who could have provided 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 a psychiatric diagnostic evaluation provided on 
October 22, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient admission provided on February 26, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the inpatient admission. You say that the enrollee was seen in the emergency 
room and had been previously hospitalized from February 10, 2022, to February 16, 2022. 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 
inpatient admission. We found no exception that would require the Plan to pay for the inpatient admission. The 
records provided for review do not show that the inpatient admission was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the inpatient admission provided on February 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a soft tissue biopsy performed on June 10, 
2022. 
 
You asked the Plan to waive the copayment for the biopsy. You say that this was done in the office and should 
not be billed as an outpatient procedure. 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 a $345 
copayment for surgery or services at an outpatient hospital.  
 
You have been asked to pay a $345 copayment for the biopsy. The biopsy is considered a surgical procedure 
and 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 a soft tissue 
biopsy performed on June 10, 2022.