Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services. 
 
You asked the Plan to pre-approve bone marrow aspirate services. You say that this procedure is medically 
reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 bone marrow aspirate services. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the enrollee is a 67-year-old male being treated for spondylolisthesis of 
the lumbar region; osseous and subluxation stenosis of intervertebral foramina lumbar region; other low back 
pain; and segmental and somatic dysfunction of the lumbar spine. He presented with lower back pain. There is low back, left buttock and down the side of the leg to the calf. He has left foot toes numbness and 
tingling with bilateral leg weakness. He has abnormal walk and poor balance issues. The pain is constant, 
shooting, and sharp. The exam reveals tenderness to palpation of the lumbosacral spine. There is a full range of 
motion with pain. 
 
The left facetectomy at L4-5 and transforaminal lumbar interbody fusion at L3-4 has been approved. However, 
there is no specific indication provided to support the request for bone marrow aspirate for the approved 
surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone 
marrow aspirate for this enrollees medical condition. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the requested bone marrow aspirate in the setting of lumbar fusion, in this case, is not medically 
reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve bone marrow aspirate services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for one pair of compression stockings (A6530) provided on 
March 4, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable 
benefit for this item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing. However, the Plan 
provides supplemental coverage for compression stockings and surgical stockings for members who meet 
certain conditions.  
 
We reviewed the case file and the Plans rules. Based on this information, we have determined that you have 
exhausted the allowable benefit for coverage of compression stockings. You purchased three pairs of 
compression stockings on this day. The Plan has now approved payment for two pairs of compression 
stockings. The Plan contract states that gradient compression stockings are covered up to two pairs every six 
months. Therefore, you have exhausted the allowable benefit for this item. Therefore, we decided that the Plan 
does not have to pay for one pair of compression stockings (A6530) provided on March 4, 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 enrollee has a past medical history 
who presents with chest pain. You state the enrollee will require daily monitoring by multiple consulting 
physicians that are all directly managing the enrollee's care and have indicated that the most appropriate level 
of care would be LTACH. The Plan denied your request. The Plan says the stay is not medically necessary 
based on LTACH criteria. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and injections on March 15, 
2022. 
 
You asked the Plan to waive the copayment for an office visit and injections. You say that you would like to 
appeal the cost share. The Plan denied your request. The Plan says the cost share applied 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 $25 
copayment and a 20% coinsurance per injection for an office visit and injections. The combined cost share is 
$28.81. 
 
You have been asked to pay a $25 copayment and a 20% coinsurance per injection for an office visit and 
injections. An office visit and injections fall within the Physician/Practitioner services, including doctor's office 
visits and Medicare Part B prescription drugs benefit categories. 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 an office visit and injections on March 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zeposia. 
 
You asked the Plan to pre-approve Zeposia. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zeposia.  
 
Benefits for Zeposia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the compression stockings identified with 
code A6533 that were issued on March 10, 2022 and March 15, 2022. 
 
You asked the Plan to issue reimbursement for the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items at issue 
are not covered under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 Although these items may be appropriate, they do not fall into a covered benefit category and cannot be paid 
for by Medicare or the Plan. Therefore, we decided that the Plan does not have to issue reimbursement for the 
compression stockings identified with code A6533 that were issued on March 10, 2022 and March 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on December 5, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you told the 
paramedics you did not need an ambulance. The Plan denied your request. The Plan says the Medicare 
ambulance benefit is a transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 5, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on December 5, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve IGRT. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says that the reason this request for daily picture studies cannot be approved is because only 
weekly picture studies are needed. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the services at issue in this case are medically reasonable and necessary because this is a 
standard technique. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve IGRT.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between wheelchair controller and 
two or more power seating system motors (E2311) and power elevating leg rests (E1012). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the enrollee meets the 
Medicare/CMS guidelines and criteria for a K0856 group 3 power wheelchair equipped with both power tilt 
and power elevating leg rests. The Plan denied your request. The Plan says the requested accessories are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the wheelchair accessories. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the requested power elevating leg rests and electronic connection are not 
medically necessary for the enrollee to properly use the approved wheelchair. The requested items exceed the 
enrollees medical need. The power tilt option was approved, and the documentation does not support the need 
for power elevating leg rests. The documentation does not reveal evidence of inability to flex to knee to 90 
degrees of flexion, significant lower extremity edema. There is no evidence of a reclining back on the 
wheelchair. The documentation does not reveal that the enrollee needs to control 2 power options on the 
wheelchair as 2 power options were not approved as medically necessary. Also the enrollee's left upper 
extremity strength and function support that any power options can be controlled with their individual switches. 
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve electronic connection between wheelchair controller and two or more power 
seating system motors (E2311) and power elevating leg rests (E1012).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 13, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that your infusion nurse advised you to 
go to the ER. You say that you did not receive treatment. 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 $90 
copayment for each emergency room visit.  
 
The file shows that you were seen and evaluated by the ER staff on March 13, 2022. Therefore, you have been 
asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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 an emergency room (ER) visit provided on March 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigations (D4921) provided on February 15, 
2022, and March 7, 2022. 
 
You asked the Plan to pay for the gingival irrigations. You say that you have a low income, and would never 
accept treatments that are not covered by your plan. The Plan denied your request. The Plan says this service is 
not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the 
date of service to verify benefits and provider eligibility. 
 
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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigations (D4921) provided on February 15, 2022, and March 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
February 22, 2022, to February 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are in worse pain 
now than when you went into the hospital. You say the bills are uncalled for, since you were released without 
being treated. 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 $325 
copayment per admission for each inpatient stay.  
 
You have been asked to pay a $325 copayment for an inpatient stay. An inpatient hospital stay 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 the inpatient 
hospital stay provided from February 22, 2022, to February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of post-surgical complications (D9930) 
provided on April 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says treatment of post-surgical complications (D9930) is not covered 
by your dental 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of post-surgical complications (D9930) provided on April 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and cone beam imaging 
(D0364) provided on April 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for a limited oral evaluation has already been 
exhausted. The Plan also says that cone beam imaging (D0364) is not covered by your routine dental 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. 
 
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 January 3, 2022. Cone 
beam imaging (D0364) is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pay for a limited oral evaluation (D0140) and cone beam imaging (D0364) provided on April 21, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a periodic oral evaluation (D0120), 
and bitewing x-rays (D0274) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not told your provider was out-of-
network. 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 you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services 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 prophylaxis (D1110), a periodic oral evaluation (D0120), and bitewing x-rays (D0274) provided on 
May 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $15 copayment for a chiropractic visit on July 1, 2021. 
 
You asked the Plan to waive the $15 copayment for a chiropractic visit. You say that you cannot afford to pay 
the assessed copayment. The Plan denied your request. The Plan says the copayment has been applied 
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 $15 
copayment for each in-network chiropractic visit. 
 
You have been asked to pay a $15 copayment for a chiropractic visit. A chiropractic visit falls within the 
Chiropractic 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 $15 copayment for a chiropractic visit on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient rehabilitation care provided from 
January 20, 2022, to January 28, 2022. 
 
You asked the Plan to waive the copayment for the inpatient rehab. You say that you feel you should not be 
billed twice for one continuous stay. 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 $350 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission, including transfers between different 
levels of care.  
 
The file shows that you were transferred from inpatient care to inpatient rehabilitation on January 20, 2022, and 
were discharged on January 28, 2022. This transfer to a different level of care is considered a new admission. 
Therefore, you have been asked to pay $350 per day for days 1-5 of inpatient rehab. The total for this stay is 
$1,750 ($350 copayment x 5 days = $1,750). The inpatient rehab 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 rehabilitation care 
provided from January 20, 2022, to January 28, 2022.