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

 
We decided that the Plan does not have to pre-approve a continuous blood glucose monitor (CGM) and 
supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. 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. 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 indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous blood glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on 
August 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 
5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) 
provided on March 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that you went to the dentist thinking you were going 
to get a partial that was covered 100%. You say that you were approved for a cleaning and implant and would 
cover $507. You also say that the quote you got did not tell you, you had to pay anything out of pocket. The 
Plan denied your request. The Plan says there is a 50% coinsurance for major restorative services, including 
periodontics. 
 
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 the dental 
services when the services are medically necessary and reasonable.  We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the file shows there is a 50% coinsurance for 
periodontics. The record shows that the Plan paid 50%, or $59.02, for each quadrant. $59.02 + $59.02 = 
$118.04. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing 
(D4341 x 2) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device. 
 
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent 
deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not 
covered by Medicare to prevent deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as 
not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
therapy, pneumatic compression device, and multivitamin injections rendered on April 6, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that TENS therapy is approved for the treatment of 
chronic low back pain, PCDs are covered for the treatment of lymphedema and chronic venous insufficiency, 
and services that are not medically necessary are not covered. 
 
We looked at the file and Medicare rules. The file shows that the enrollee received TENS therapy and PCD 
therapy for the treatment of foot drop. This is not a diagnosis for which these services are covered. There is no 
documentation to support that the multivitamin injections were necessary to diagnose and treat the enrollee. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) therapy, pneumatic compression device, and multivitamin injections rendered on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on May 5, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the special anesthesia services rendered on May 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits.
You asked the Plan to pre-approve 3 home health skilled nursing visits. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 3 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 home health skilled nursing visits
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on January 8, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on January 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 9, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 61543 is not supported.
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, the CPT Code Manual definition of code 61543 is craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy. We find that CPT code 61543 is not supported in the medical record. Specifically, there is no documentation of
a craniotomy with elevation of bone flap for partial or subtotal hemispherectomy. Based on this information,
we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that
the Plan does not have to pay for the surgical services rendered on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the lab services provided on June 21, 2021. 
 
You asked the Plan to waive the copay for the lab services. You say that the labs were part of your annual 
physical. The Plan denied your request. The Plan says the copay was applied per your benefits. 
 
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 $10 
copay per day for laboratory tests.  
 
You have been asked to pay a $10 copay per day for the lab services. The services fall within the outpatient 
diagnostics tests benefit category. Your plan contract says that if you receive services during an annual physical 
that address a medical condition, additional cost shares may apply. 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 copay for the lab services provided on June 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided 
April 30, 2021 to May 14, 2021. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you received a bill from the 
hospital for $2,030.00 regarding inpatient rehabilitation after back surgery. You had already paid for this the 
first time you went for the surgery. The Plan denied your request. The Plan says this claim was processed with 
the correct copayment applied per the Evidence of Coverage. 
 
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 $290 
copayment for each Medicare covered day for days 1-7 $0 copayment for each additional day.  
 You have been asked to pay $2030.00 ($290 x 7 days) for the inpatient stay. The inpatient 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 
rehabilitation stay provided April 30, 2021 to May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this is a medically necessary 
procedure that should be covered. The Plan denied your request. The Plan says this is an experimental 
procedure and is 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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested spacer remains experimental at this time. More research is needed to 
show safety and efficacy of the 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the laboratory services rendered on March 3, 2021. 
 
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says that the coinsurance was 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 does not say in clear and accurate 
terms how much you should expect to pay for laboratory tests.  
 
We looked at your contract with the Plan. The contract states that you pay a 0-20% coinsurance for laboratory 
tests; however, there is no further information regarding how the percentage between 0 to 20 is applied. The 
Plan contract does not clearly say exactly how much enrollees must pay for laboratory tests. This means that 
the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that 
the Plan has to waive the coinsurance for the laboratory services rendered on March 3, 2021.  
 
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 must 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 waive the copayment for the diagnostic examination of the bladder 
and bladder canal (urethra) using an endoscope (52000) provided March 19, 2021. 
 
You asked the Plan to waive the copayment for the diagnostic service. You say that the Plan should cover part 
of the copayment. The enrollee was examined. $225 for an exam is outrageous. The Plan denied your request. 
The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $225 
copayment for services provided at an ambulatory surgical center.  
 
You have been asked to pay $225 copayment for the diagnostic service. The diagnostic service falls within the 
Outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the diagnostic examination of the bladder and bladder canal (urethra) using an endoscope 
(52000) provided March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 26, 2021 by a 
non-network provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by a non-network provider without prior authorization. 
 
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 referring provider 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 the laboratory services provided on January 26, 2021 by a non-network 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 IRF care. You say that the enrollee will not be able to make enough gains at 
a lower level of care. The Plan denied your request. The Plan says the enrollee does not require an 
interdisciplinary team approach for rehabilitation care. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for acute appendicitis, dehydration and demand 
ischemia. Her medical problems are stable. The complexity of her nursing, medical and rehabilitation needs 
does not 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 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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]  You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like reconsideration because these services are medically necessary and ouu are having difficulty writing. The Plan denied your request. The Plan says this provider is not a Medicare qualified mental health care professional.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is a Licensed Professional Counselor and Marriage and Family Therapist. This provider does not meet the criteria of a Medicare qualified mental health care professional. Therefore, we decided that the Plan does not have to pay for [complete description of item or service at issue, e.g. at issue is "a power wheelchair provided by The Wheelchair Store on January 12, 2016."]
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the two resin-based composites (D2392 x2) provided 
on February 27, 2021. 
 
You asked the Plan to pay for the resin-based composites. You say that you were not aware that the treating 
provider was not in-network. The Plan denied your request. The Plan says your dental allowance has 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, the Plan offers up to a $230.00 
allowance for covered comprehensive dental services every quarter. The record shows that you met the annual 
maximum benefit while processing this claim for the February 27, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay in full for the 
two resin-based composites (D2392 x2) provided on February 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on April 
19, 2021.  
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The cardiovascular risk assessment testing at issue in this appeal was requested solely for screening purposes. 
Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the cardiovascular risk assessment testing provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 
3, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 3, 
2021.