Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve an upper partial denture, flexible base (D5225). 
 
You asked the Plan to pre-approve an upper partial denture. You say that you have a supporting metal in your 
upper tooth on one side with a path and a canal that is sore and unresolved. You do not have support of your 
teeth from that side to the other side of your mouth. The articulation hurts your tooth when chewing and soon 
you will not be able to chew on either side. The Plan denied your request. The Plan says that the requested 
service is not covered with 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 an upper 
partial denture 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 an upper partial denture have been met. Specifically, the plan contract does not specify the specific 
type of partial upper dentures that are covered. Therefore, we decided that the Plan has to pre-approve an upper 
partial denture, flexible base (D5225).  
 
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 pay for the inpatient hospital services related to a transcatheter mitral 
valve repair (TMVR) provided from January 16, 2022, through January 20, 2022. 
 
You asked the Plan to pay for the inpatient hospital services as billed. You say that this service was approved 
but then denied for missing clinical trial number. There is no reason that this claim should not have paid. The Plan denied your request. The Plan says this claim was not billed correctly for providing a service covered 
under CED. 
 
The Plan must follow Medicare rules. Medicare rules say that TEER services are covered under CED. The 
rules indicate various requirements for the billing for services under CED as noted in the Medicare rules 
section of this decision. 
 
We looked at the file and Medicare rules. The claim was deficient for clinical trial services in several ways. 
There was no value code D4 reported with the clinical trial number. Diagnosis code Z00.6 was also not 
reported, nor was condition code 30. These are all required to allow payment for services provided under CED. 
Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services as 
billed have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
services related to a transcatheter mitral valve repair (TMVR) provided from January 16, 2022, through 
January 20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vertebral axial decompression (S9090) provided to the 
enrollee from January 5, 2022, to February 17, 2022. 
 
You asked the Plan to pay for the services. You say that this was once a covered service. The Plan denied your 
request. The Plan says there is insufficient data to support the benefit of this 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 S9090 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9090 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
vertebral axial decompression (S9090) provided to the enrollee from January 5, 2022, to February 17, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require dialysis 
three times a week. The Plan denied your request. The Plan says that this request exceeds the benefit limit. 
 
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 a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing identified with code 87631 provided on February 
1, 2022. 
 
You asked the Plan to pay for the testing. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or 
more pathogens are non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that the testing rendered is specifically not 
covered. Based on this information, we decided that Medicare rules for coverage of the testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the testing identified with code 87631 
provided on February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment and procedures with an oncologist to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve treatment and procedures with an oncologist. You say that you do not have 
transportation and you are requesting treatment at the City of Hope in Temecula because your aunt would be 
able to take you for treatments. The Plan denied your request. The Plan says it is not required to pay for out of 
network services that can be provided in-Plan. The Plan also says there are in-network providers available, 
including a second opinion. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
treatment and procedures with an oncologist to be provided by an out-of-network (OON) provider.  Your complaint about your throat diagnosis 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the laboratory services provided on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for toenail debridement provided on March 10, 2022. 
 
You asked the Plan to pay for toenail debridement. You say that you are unable to bend to cut your toenails that 
are growing up and thick instead of growing out and regular toenail clippers will not cut them. The Plan denied 
your request. The Plan says you do not have diabetes and had no symptoms of foot disease. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of toenail debridement provided on 
March 10, 2022 have been met. There are no medical records provided for review. Therefore, we decided that 
the Plan does not have to pay for toenail debridement provided on March 10, 2022.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the services the enrollee needs can be provided safely in other settings. 
 
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. The 
enrollee is medically stable and does not need physical medicine and rehabilitation physician's supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. There are no acute rehab nursing needs identified or documented. At the current functional 
level, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day at least 5 
days per week with multidisciplinary approach in an IRF. While the enrollee may benefit from continued 
physical and occupational therapy, her rehab needs can be safely provided in a lower intensity and alternate 
setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the telehealth visits provided on January 
11, 2022, January 12, 2022, January 15, 2022, January 18, 2022, and January 21, 2022. 
 
You asked the Plan to waive the copayments for the telehealth visits. You say that you should not be 
responsible for the calls your physician made about your diagnosis. The Plan denied your request. The Plan 
says the proper copayments were applied for the services that were rendered. 
 
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 
copayment for each office visit or telehealth visits to your PCP. There was a total of 5 telehealth visits during 
the dates of service with a total copayment amount of $50 (5 visits x $10 copayment). 
 
  You have been asked to pay a $50 copayment for the telehealth visits. The telehealth visits falls within the 
Physician/Practitioner services, including doctors 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 copayments for the telehealth visits provided on January 11, 2022, January 12, 2022, January 15, 
2022, January 18, 2022, and January 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to lower your coinsurance for outpatient surgery and therapy services 
provided from December 14, 2021, to December 15, 2021. 
 
You asked the Plan to lower your coinsurance for outpatient surgery and services provided from December 14, 
2021, to December 15, 2021. You say that you should only be responsible for an inpatient copayment. The Plan 
denied your request. The Plan says you are responsible to pay a 20% coinsurance for outpatient surgery. 
 
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% 
coinsurance for Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers and a $40 copayment for each Medicare-covered therapy visit.  
 You have been asked to pay a 20% coinsurance for outpatient surgery. Outpatient surgery falls within the 
Outpatient Surgery Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers benefit category. Records submitted support that you were not admitted as an inpatient. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. You have also been 
asked to pay a $28.86 copayment for physical therapy services and a $17.41 copayment for occupational 
therapy services. This means that you have been asked to pay less than your contracted amount 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 lower your coinsurance for outpatient surgery and therapy services 
provided from December 14, 2021, to December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day Sensor. 
 
You asked the Plan to pre-approve the sensor. You say that the sensor is necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 enrollee is not receiving insulin shots 3 or more times a day or 
using an insulin pump. Based on this information, we decided that Medicare rules for coverage of the sensor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 14 Day 
Sensor.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says IRF admission is not medically necessary and the enrollee is medically 
stable. 
 
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 that while the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services an IRF would provide. 
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with computed 
tomography (CT) for attenuation. 
 
You asked the Plan to pre-approve a PET CT scan for attenuation. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
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 a PET CT scan for attenuation. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has had 
therapy for his prostate cancer and the more than doubling of his prostate-specific antigen (PSA) is worrisome 
for recurrence or metastases. As such he qualifies for a prostate specific PET/CT per CMS guidellines. 
 
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 PET CT scan for attenuation have been met. Therefore, we decided that the 
Plan has to pre-approve a positron emission tomography (PET) with computed tomography (CT) for 
attenuation.  
 
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 pay for subsequent hospital and observation care services (99224, 
99232) provided on October 9, 2021, and October 10, 2021. 
 
You asked the Plan to pay for hospital and observation care. You say that these services were billed 
appropriately. The Plan denied your request. The Plan says there is no documentation provided to support the 
services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of these services have been met. Specifically, no medical records were provided to support the services billed. Therefore, we decided that the 
Plan does not have to pay for subsequent hospital and observation care services (99224, 99232) provided on 
October 9, 2021, and October 10, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) care for the enrollee. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not at his prior level of functioning. 
The Plan denied your request. The Plan says that that the enrollee's needs can be safely and better managed in a 
less restrictive setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that 
continued SNF care is medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. The enrollee has recently developed 
improved cognition and is starting to make progress with therapies. Ongoing daily skilled services are 
reasonably required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
To stop services as the enrollee is just starting to improve, would likely result in cessation of progress and/or 
deterioration of the enrollees condition. Our physician reviewer found that the enrollee's condition meets 
Medicare criteria for continued SNF 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 SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued 
skilled nursing facility (SNF) care for the enrollee.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care attendant services. 
 
You asked the Plan to pre-approve personal care attendant services. The Plan denied your request. The Plan 
says personal care attendant services is not covered under Medicare and may be covered under your Medicaid 
benefits. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file, the Plans rules and Medicare rules. Based on this information, we decided that Medicare 
rules for coverage of personal care attendant services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve personal care attendant services.