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

 
We decided that the Plan has to pre-approve a posterior opening socket (L5634), socket insert (L5654), and 
below-knee ultra-light material exoskeletal system (L5785) for a lower limb prosthesis. 
 
You asked the Plan to pre-approve lower limb prosthetic components. You say that you need this to safely 
navigate day-to-day living. The Plan denied your request. The Plan says that this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lower limb prosthetic components. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have a history of right-sided transmetatarsal amputation in 2016 due to 
complication from diabetes. Clinical documentation indicates that your toe filler or transmetatarsal prosthesis is 
broken and in need of replacement because it cannot be repaired. It is appropriate for your medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lower limb prosthetic components have been met. Therefore, we decided that 
the Plan has to pre-approve a posterior opening socket (L5634), socket insert (L5654), and below-knee ultra-
light material exoskeletal system (L5785) for a lower limb prosthesis.  
 
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 a genicular nerve block provided on August 12, 2022.

You asked the Plan to pay for the genicular nerve block. You say that the genicular nerve block was medically necessary. The Plan denied your request. The Plan says genicular nerve blocks are investigational and not medically necessary for the treatment of chronic knee pain.

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 genicular nerve block. Our reviewer says that the requested genicular nerve block is not considered medically reasonable and necessary. Our physician reviewer found that genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered experimental/investigational in nature.

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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pay for a genicular nerve block provided on August 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH level of care is most 
appropriate for the enrollee to achieve the best outcome due to their complex medical needs. The Plan denied 
your request. The Plan says the requested LTACH services are not medically necessary. 
 
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 documentation does not support that the enrollee has a need for complex medical 
treatment in an LTACH. The enrollee does not require services at the LTACH that are not available at the acute 
care hospital or the skilled nursing facility. The requested treatments are not medically necessary at the 
LTACH level of care. The enrollee has improved medically and can receive further care at the current acute 
care hospital or a lower level of care when deemed appropriate.   
 
 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 (LTACH services.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found clinical documentation shows that enrollee has active medical comorbidities/hospital complications and 
complex functional impairments thus the complexity of the patient's documented nursing, medical and 
rehabilitation needs would be expected to require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute IRF admission and services.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 43246 billed for date of service January 6, 
2022. 
 
You asked the Plan to pay for procedure code 43246. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 43246 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 43246 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 43246 billed for date of service January 6, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mental health visit provided on July 24, 2022. 
 
You asked the Plan to pay for mental health visit. You say that this should be covered. The Plan denied your 
request. The Plan says the Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for mental health visit provided on July 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that there was a limitation 
of one procedure per plan year. You also say that the services were due to pain with your teeth on both dates of 
service. The Plan denied your request. The Plan says your benefit for the requested item or service has already 
been exhausted. 
 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 10, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on November 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 
25, 2022. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you never had a copay for this 
service before. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 Medicare-covered specialist office visit.  
 
You have been asked to pay a $11.78 copayment for a specialist visit because the allowed amount for this 
service is less than the $35 copayment. This item/service falls within the Medicare-covered specialist office 
visit 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 specialist office visit provided 
on August 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve procedure codes E2373, E2377, E2313, E2311, and 
E1012. 
 
You asked the Plan to pre-approve procedure codes E2373, E2377, E2313, E2311, and E1012. You say that the 
enrollee needs this chair to remain functional and avoid skin breakdown. You also say that the enrollee was hit 
by a car in October 2022 and needs a new chair as a result. The Plan denied your request. The Plan says 
procedure code E2373 exceeds the enrollee's need. The Plan says there is no medical need for procedure codes 
E2377, E2313, E2311. The Plan also says that procedure code E1012 has previously been approved. 
 
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 procedure codes E2373, E2377, E2313, 
E2311, and E1012. Our reviewer says that the requested power wheelchair accessories are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the provided documentation 
does not support that it is medically necessary to control the requested power options through the joystick 
(drive interface). The documentation indicates the enrollee's upper extremity strength and functional ability as 
evidenced by being independent for bathing, toileting and for feeding should be sufficient to control any power 
options through their own switches. Therefore, the reviewer found that the upgraded electronics are not 
medically necessary. The reviewer found that since an expanded controller is not medically necessary, neither 
is a mini joystick. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes E2373, E2377, E2313, E2311 have not been met. Additionally, 
the record shows that the Plan already approved procedure code E1012. Therefore, we decided that the Plan 
does not have to pre-approve procedure codes E2373, E2377, E2313, E2311, and E1012.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve subsequent chiropractic manipulative treatments 
(98940). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of the 
requested services.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan contract provides supplemental coverage 
for chiropractic services.  
 
The records show that subsequent chiropractic manipulative treatments will need to be authorized after the 
initial chiropractic examination. Therefore, we decided that the Plan does not have to pre-approve subsequent 
chiropractic manipulative treatments (98940).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 20, 2022. 
 
You asked the Plan to pay for an office visit. You say that an authorization was not required. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on October 20, 2022.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to lower the cost share for CT scan. We decided that the Plan does not have to 
waive the cost share for cardiac rehabilitation services and a CT scan.  
 
You asked the Plan to waive the cost share for a computed tomography (CT) scan provided on July 11, 2022. 
You say that the coding was incorrect and would like someone to look into it. The Plan says that this cost 
sharing was charged correctly.  
We decided that the Plan has to lower the cost share for CT scan.  
 
The Plan follows Medicare rules. 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 enrollees must pay a 10% coinsurance for CT 
scan. 
 
The Plan says you must pay a $25 copayment for a CT scan. Based on the Plan contract, however, you cannot 
be asked to pay more than a 10% coinsurance for the CT scan. The total allowed amount for the CT scan is 
$193.94. You are being asked to pay $19.39 ($193.94 x 10% = $19.39). 
 
Therefore, we decided that the Plan has to lower the coinsurance for the CT scan provided on July 11, 2022. 
 
We also decided that the Plan does not have to waive the cost share for cardiac rehabilitation services 
and a CT scan. 
 
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 10% 
coinsurance for a CT scan. Your contract also says you must pay a $40 copayment per visit for cardiac rehab 
services. However, you are only being charged $30 per visit which is less than the required amount. You are 
being asked to pay $750 ($30 x 25 visits = $750). The total amount for all services rendered is $769.39 ($750 + 
$19.39 = $769.39). Therefore, we decided that the Plan does not have to waive the cost share for cardiac 
rehabilitation services and a CT scan. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say the enrollee would strongly benefit from skilled nursing 
care, and you would like reconsideration based on the records submitted. The Plan denied your request. The 
Plan says the requested SNF admission is not medically necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye exam and refraction provided on October 7, 2022. 
 You asked the Plan to pay for the eye exam and refraction. You say that the eye exam should be covered due to 
your underlying health conditions. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when done as a part of a routine eye exam. 
 
We looked at the file and the Plan's rules. Specifically, the refraction was not performed with a routine eye 
exam. The medical record shows diagnoses of myopia, astigmatism, minor opacity of cornea, hypermetropia, 
and presbyopia which makes the eye exam medical in nature. Based on this information, we decided that the 
Plan's rules for coverage of the eye exam and refraction have not been met. Therefore, we decided that the Plan 
does not have to pay for the eye exam and refraction provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a subsequent nursing facility care visit provided on 
November 30, 2022. 
 
You asked the Plan to pay for a subsequent nursing facility care visit. You say that the records attached support 
the services provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is 
not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a subsequent nursing 
facility care visit provided on November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on September 15, 2022. 
 
You asked the Plan to pay for an office visit. You say that the records attached support the services provided. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on September 15, 2022.