Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on February 
9, 2022. 
 
You asked the Plan to waive the coinsurance for anesthesia services. You say that you were not informed of 
any additional charges prior to surgery by the provider performing the surgery or the outpatient surgery center. 
You also say that you were told you would only pay a $250 copayment per eye. You also say that the Plan told 
you that the provider was out-of-network, but the providers say they are in-network. The Plan denied your 
request. The Plan says you were 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 30 
percent coinsurance for out-of-network surgery services.  
 
You have been asked to pay $17.70 in coinsurance, which is 30 percent of the allowed amount for anesthesia 
services ($59 allowed amount x 30% coinsurance = $17.70). Anesthesia services 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 coinsurance for anesthesia services provided on February 9, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on January 28, 2022. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were not informed there would 
be a coinsurance cost at the time of the visit for this service. The Plan denied your request. The Plan says the 
coinsurance amount 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). The allowed amount of this drug is $1023.72, resulting in a 
coinsurance amount of $204.74. 
  
You have been asked to pay a 20% coinsurance for Part B Non-Chemotherapy Drugs 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 January 28, 2022.  
 Your complaint about the providers staff not notifying you of the coinsurance 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH care is correct. 
 
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 still requires additional acute care services before transitioning to a lower 
level of care. The enrollee continues to receive acute care services that have not been denied. The record does 
not indicate that the enrollee requires services at the LTACH that are not available at the current acute care 
facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve application of skin grafts. 
 
You asked the Plan to pre-approve skin grafts. You say that the enrollee has not responded to conservative care 
or more advanced therapy, so more aggressive treatment is needed. The Plan denied your request. The Plan 
says the denial of authorization for this service is correct, because there is no indication that the enrollee's 
wounds are clear of infection. 
 
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 skin grafts. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical note from June 23, 2022 documents signs of infections which is a contraindication 
to skin grafting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin grafts have not been met. Therefore, we decided that the Plan does not 
have to pre-approve application of skin grafts.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a placement of a spinal neurostimulator. 
 
You asked the Plan to pre-approve a placement of a spinal neurostimulator. You say that the requested services 
are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have 
not been met because a trial of a temporarily implanted neurostimulator has not been completed. 
 
The Plan must follow Medicare rules. The rules say that no payment may be made for the implantation of 
dorsal column stimulators unless all of the conditions listed in the Medicare rules section have been met. 
 
We looked at the file and Medicare rules. In this case, the available medical records indicate that placement of 
a temporary neurostimulator proved to be not possible. Therefore, the case record does not contain a 
demonstration of pain relief with temporarily implanted neurostimulator. Based on this information, we decided that Medicare rules for coverage of a placement of a spinal neurostimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a placement of a spinal neurostimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 21 and 28, retainer crowns 
(D6750) for tooth #'s 22 and 27, and pontics (D6240) for tooth #'s 23, 24, 25, and 26. 
 
You asked the Plan to pre-approve the crowns, retainer crowns, and pontics. You say that you have a $3,000 
allowance for Medicare and would like to know why you cannot use this allowance for these services. The Plan 
denied your request. The Plan says the crowns are denied because needed x-rays were not provided. The Plan 
also says that pontics and retainer crowns are not covered by your plan. 
 
  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 crowns 
(D2750) 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 crowns (D2750) for tooth #'s 21 and 28. 
Our reviewer says that the documentation provided does not meet the criteria for coverage for crown 
restorations for teeth #'s 21 and 28. Our physician reviewer found there is no narrative indicating why crown 
restorations are needed for tooth #'s 21 and 28. Our reviewer also found that the x-rays provided do not show 
significant coronal breakdown due to caries or fracture to warrant crown restorations. 
 
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 crowns, retainer crowns, and pontics have not been met. Therefore, we 
decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 21 and 28, retainer crowns 
(D6750) for tooth #'s 22 and 27, and pontics (D6240) for tooth #'s 23, 24, 25, and 26.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion with an out of network (OON) 
oncology provider. 
 
You asked the Plan to pre-approve a second opinion with an OON oncology provider. You say that you are 
disturbed about the level of care the enrollee has received with network physicians. You say that the network 
providers the enrollee has seen demonstrated the lack of expertise they have and have put her life at risk. You 
say that it is imperative that the enrollee be seen by the requested OON provider who are experts in the 
diagnosis and treatment of a suspected rare and lethal disease. The Plan denied your request. The Plan says 
referral to the OON provider is not medically necessary as appropriate services are available in-network. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 second opinion with an OON 
oncology provider. Our reviewer says that the criteria for coverage of OON care have not been met. Our 
physician reviewer found any trained in network oncologist can recommend treatment including chemotherapy 
for this aggressive neoplasm. The adrenal hemorrhage is to have follow-up magnetic resonance imaging (MRI.) 
The Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's needs 
through referral to their in-network providers. There is nothing unique about the enrollee's condition that would 
make it medically necessary for her to see the requested OON oncologist. The Plan has shown that they have 
network providers who meet the Standards of Care required for treatment of the enrollee's 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 a second opinion with an OON oncology provider have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a second opinion with an out of network 
(OON) oncology provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 2 continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve FreeStyle Libre 2 CGM. You say that you have a medical condition that 
makes it nearly impossible to check your blood sugars with a traditional glucose monitor. The Plan denied your 
request. The Plan says you do not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of FreeStyle 
Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle 
Libre 2 continuous glucose monitor (CGM)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a La-Z-Boy recliner. 
 
You asked the Plan to pre-approve a La-Z-Boy recliner. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
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 a La-Z-Boy recliner.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the device will help improve the 
enrollee's glycemic control. The Plan denied your request. The Plan says the authorization criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation does not indicate that the enrollee use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve for percutaneous implantation of neurostimulator 
electrode array, SPRINT PNS system (64555). 
 
You asked the Plan to pre-approve the SPRINT PNS system. You say that the denial for this procedure is 
unwarranted and unsupported by the enrollee's current medical status and published data. Proof of medical 
necessity was sufficiently and precisely documented in the preservice/prior authorization request. The Plan 
denied your request. The Plan says current literature does not support the use of SPRINT PNS system for this 
enrollee's pain. It is still under review for overall support for use in chronic pain management. Further studies 
are needed to evaluate the efficacy of PNS. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SPRINT PNS system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve for percutaneous implantation of neurostimulator electrode array, SPRINT PNS system (64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and related accessories. 
 
You asked the Plan to pre-approve the requested services. You say that the wheelchair is needed due to the 
enrollee's progressive disease. The Plan denied your request. The Plan says the power options are not needed. 
 
The Plan must follow Medicare rules. The rules say that power wheelchairs and accessories are only covered 
under certain medical indications.  
 
We looked at the file and the rules. The file shows that a Group 3 power wheelchair with tilt, recline, and leg 
rests were requested. The records provided do not show that the enrollee has significant edema in the lower 
extremities, is at high risk for pressure ulcers, utilizes catheterization, or needs increased tone or spasticity. 
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair and related accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable oxygen contents, gaseous, 1 month's supply 
(E0443). 
 
You asked the Plan to pre-approve portable oxygen contents. You say that the oxygen context is medically 
necessary for the enrollee. The Plan denied your request. The Plan says this item is inclusive of reimbursement 
as part of an oxygen concentrator, and/or portable oxygen rental payments and no separate authorization is 
required for this oxygen supply and is not billable during the initial 36-month rental period. The Plan must follow Medicare rules. Medicare rules say that items and services that are not billable during the 
initial 36-month rental period. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable oxygen contents have not been met. Therefore, we decided that the Plan does not have to 
pre-approve portable oxygen contents, gaseous, 1 month's supply (E0443).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on June 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that 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 
outpatient office visit. We found no exception that would require the Plan to pay for the outpatient office visit. 
The records provided for review do not show that the outpatient office visit was urgent or emergent. Therefore, 
we decided that the Plan does not have to pay for the outpatient office visit provided on June 30, 2021, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH is the appropriate level of care 
for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH care is 
correct. 
 
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 does not require services at the LTACH that are not available at the 
current acute care hospital. All medically necessary care is being provided in the current acute care 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visits provided from February 2, 
2022 to February 4, 2022. 
 
You asked the Plan to waive the copayment for telehealth visits. You say that you were unaware that you 
would be charged. The Plan denied your request. The Plan says you have been charged the correct copayment 
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 $25 
copayment for each Medicare-covered specialist visit and specialist telehealth visit.  
 
You have been asked to pay a total of $75 ($25 x 3 visits = $75). The telehealth visits fall within the 
Physician/Practitioner services, including doctor's 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 copayment for telehealth visits provided from February 2, 2022 to February 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) and the therapeutic exercises (97110) 
provided on August 4, 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 are not a covered benefit under 
the enrollee's contractual policy or by Medicare. 
 
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 records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the office visit (99203) and the therapeutic exercises (97110) provided on 
August 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service November 
16, 2021. 
 
You asked the Plan to pay for procedure code 99291. You say that this service was billed appropriately. The 
Plan denied your request. The Plan says payment for code 99291 is bundled into payment for code 36556. 
 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 99291 
is a column II code to column I code 36556. 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 99291 billed for date of service November 16, 
2021.