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

 
We decided that the Plan does not have to pre-approve proton treatment delivery. 
 
You asked the Plan to pre-approve proton treatment delivery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 proton treatment delivery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or 
more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The 
generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, 
and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton treatment delivery have not been met. Therefore, we decided that the 
Plan does not have to pre-approve proton treatment delivery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wig. 
 
You asked the Plan to pre-approve a wig. You say that the patients condition in which she is needing the 
cranial prosthesis is due to Alopecia totalis. The Plan denied your request. The Plan says Medicare guidelines 
say that this item is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit 
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the 
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As 
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would 
provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on 
December 15, 2021. 
 
You asked the Plan to waive the copayment for an EKG. You say that in the past you have never had to pay 
any copayment for your physical or the electrocardiogram that is supposed to be covered with it. 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 $20 
copayment for diagnostic testing, including EKGs in a physician's office.  
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay 
the allowed amount of $14.45, which is less than the $20 copayment for an EKG. An EKG falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for an electrocardiogram (EKG) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 4, 2022.
You asked the Plan to pay for the dental services. You say that you have been advised that you need 3 cleanings per year because of previous work in your mouth. The Plan denied your request. The Plan says that the frequency limit has been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the file does not include documentation to substantiate that the Plan has paid for 2 oral exams and 2 cleanings within 12 months. Without this information we cannot determine that the frequency limit has been reached. Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on February 4, 2022.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. The requested service cannot be recommended. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power wheelchair, group 2 heavy duty, sling/solid 
seat/back, patient weight capacity 301 to 450 pounds (CPT code K0824). 
 
You asked the Plan to pre-approve the DME. You say that you have enough room and space to operate a power 
wheelchair. The Plan denied your request. The Plan says your request is not medically necessary because your 
records do not demonstrate that you need this device to perform MRADLs inside the home, and the records do 
indicate that this device is requested specifically for use outside the home. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 DME. Our physician reviewer 
found there is no documentation that you have a personal mobility deficit that impairs participation in mobility 
related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within 
the home. Records indicate the power wheelchair is being requested for use outside the home, "getting out to 
the mall, visiting grandchildren." There is no documentation that your mobility deficit in the home cannot be 
helped by the use of a walker, cane or manual wheelchair. There is documentation that you can safely operate a 
power mobility device. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 
450 pounds (CPT code K0824).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an over-the-counter (OTC) home COVID-19 antigen test 
(87811) purchased on December 11, 2021. 
 
You asked the Plan to pay for an OTC COVID-19 test. You say that you were showing signs of COVID-19 and 
this test was necessary. The Plan denied your request. The Plan says over-the-counter medications and items 
are not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and an OTC 
COVID-19 test is an OTC item. Therefore, we decided that the Plan does not have to pay for an over-the-
counter (OTC) home COVID-19 antigen test (87811) purchased on December 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided from 
August 29, 2021, to September 1, 2021. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital care. You say that these claims had to do 
with being in the hospital when you had CoViD. The Plan denied your request. The Plan says the cost sharing 
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 15% 
coinsurance for each Medicare-covered hospital stay.  
 
 
 You have been asked to pay $76.56 for the inpatient hospital care. The inpatient hospital 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 waive the coinsurance for inpatient 
hospital care provided from August 29, 2021, to September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a needle biopsy procedure performed on 
December 16, 2021. 
 
You asked the Plan to waive the copayment for the needle biopsy. You say that the results from the first biopsy 
were inconclusive. You say that the enrollee should not have to pay for the procedure since there was an error. 
The Plan denied your request. The Plan says the enrollee was 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $350 copayment for outpatient surgery in an outpatient hospital facility.  
 
The enrollee has been asked to pay a $350 copayment for the needle biopsy. The needle biopsy falls within the 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the 
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in 
the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a needle biopsy 
procedure performed on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a general dentist visit with an out of network dentist. 
 
You asked the Plan to pre-approve out of network dental services. You say that this is the only dental provider 
you have the availability to drive to. You say that you have been with this dentist for the past couple of years. 
You also say that you want to continue to get your dental work done by this provider to their location. The Plan 
denied your request. The Plan says there are in network dentists available that that provide these services. 
 
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 request to see an out of network 
dentist is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a general dentist visit with an out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services provided on June 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for surgical services. You say that you want payment approved for the medically 
necessary services provided in good faith to member. The Plan denied your request. The Plan says the 
rendering provider is a non-participating provider, and they did not authorize any services for the facility or the 
provider. 
 
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 surgical services provided on June 2, 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve the IRF care. The Plan denied your request. The Plan says the records do 
not show that you require aggressive therapies by an intensive team in order to properly regain your function or 
that you need to be seen by a rehab doctor at least 3 times a week for evaluation of functional and medical 
goals and progress. The Plan also says that you can safely receive the services you need, intermittent therapy 
services, in other settings, for example: a skilled nursing facility, home with home health services or home with 
outpatient therapy. 
 
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 the 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 you do not require the intensity of services provided at an IRF. Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Our 
reviewer also found that your care needs can be met at a lower level of 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 the IRF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device (L8702). 
 
You asked the Plan to pre-approve the MyoPro Motion G device. You say that the MyoPro is a covered device 
within the DME benefit category under Original Medicare. The Plan denied your request. The Plan says this 
item is considered experimental and investigational. There is insufficient evidence of its safety for long term 
use and its effectiveness. 
 
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 MyoPro Motion G device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G device (L8702).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation mileage. 
 
You asked the Plan to provide additional mileage. You say that this transportation is necessary for you to see 
this provider. The Plan denied your request. The Plan says your benefit covers routine transportation trips with 
a maximum driving distance of 50 miles. Trips that exceed 50 miles are not covered. 
 
 
 
 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 trips that are to or from Plan-approved locations and do not exceed 
50 miles of driving distance.  
 
We looked at your request, the records in the case file, and the rules. The requested location is greater than 50 
miles away. 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 provide additional routine 
transportation mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the percutaneous transcatheter placement of intracoronary 
stents for two additional coronary artery branches (billed with two units of code 92929) and the initial 
observation care (billed with code 99218) for services provided on October 22, 2021. 
 
You asked the Plan to pay for the billed services. You say that this was not denied correctly. The Plan denied 
your request. The Plan says code 92929 is not separately payable, and code 99218 is not payable in the 
inpatient place of service.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 92929 has a status indicator of B on the Physician Fee Schedule. This means that CPT 
code 92929 is not separately payable. Code 99218 is for outpatient services, which are not payable for the 
inpatient place of service reported. Based on this information, we decided that Medicare rules for coverage of 
the billed services have not been met. Therefore, we decided that the Plan does not have to pay for the 
percutaneous transcatheter placement of intracoronary stents for two additional coronary artery branches (billed 
with two units of code 92929) and the initial observation care (billed with code 99218) for services provided on 
October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled 
rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician 
with at least 3 visits weekly to regain or maintain your functional status. You can receive further services at a 
lower level of 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve dentures. You say that these dentures are necessary. The Plan denied your 
request. The Plan says prosthodontic services (dentures) are not covered by your dental benefit. 
 
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 pre-approve a 
complete upper denture (D5110) and a partial lower denture (D5214).