Persius/hicric huggingface dataset:
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 you would like reconsideration because the 
requested IRF care is medically necessary. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for coverage of the IRF 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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a telephone alert system (E1399). 
 
You asked the Plan to pre-approve the telephone alert system. You say that this system is medically necessary. 
The Plan denied your request. The Plan says this device is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that telephone alert systems do not serve a diagnostic 
or therapeutic purpose and are non-covered. 
 
We looked at the file and Medicare rules. This system is non-covered. Based on this information, we decided 
that Medicare rules for coverage of the telephone alert system have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a telephone alert system (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the resin-based composite - three 
surfaces, posterior (D2393) provided October 12, 2021. 
 
You asked the Plan to provide additional payment for the filling. You say that this service is covered under 
your benefits. The Plan denied your request. The Plan says this service has been paid according to your 
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 Plan covers multi-surface 
fillings as silver fillings. 
 
We looked at the file and Medicare rules. The filling provided was a multi-surface filling. The Plan has 
processed and paid this multi-surface filling as a silver filling according to the plan contract.  Therefore, we 
decided that the Plan does not have to provide additional payment for the resin-based composite - three 
surfaces, posterior (D2393) provided October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 17, 2021, to September 16, 2021. 
 
You asked the Plan to pay for dental services. You say that you believe that the Plan should be paying for this. 
The Plan denied your request. The Plan says the total dental allowance of $2,000 has already been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services up to $2,000.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for a 
$2,000 max allowance coverage for dental services have already been met.  Therefore, we decided that the Plan does not have to pay for dental services provided by an out-of-network provider on April 17, 2021, to September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313), and a power seat elevation system (E2300) for use with an approved 
power wheelchair (PWC). 
 
You asked the Plan to pre-approve the requested PWC components. You say that it is felt that the requested 
items are medically necessary. The Plan denied your request. The Plan says the expandable controller is not 
medically necessary, and power seat elevation is not covered by Medicare. 
 
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 power seat elevation (E2300) is noncovered. 
 
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 requested PWC components. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested controller is not medically necessary as the enrollee does have use of 
her hands and can operate and control the power options using the switches that are included with the system. 
 
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 requested PWC components have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an expandable controller (E2377) with related electronic connections 
(E2311) and harness (E2313), and a power seat elevation system (E2300) for use with an approved power 
wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the consultation (D9310), therapeutic 
parenteral drug (D9610), extractions (D7140 x 10), and surgical extractions (D7210 x 7) provided on March 
10, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you were advised you 
would have to pay $90 per month for a small help policy. You say that you received a bill for $150 per month. 
You say that you cannot afford to pay this on your limited income. You also say that you need help. The Plan 
denied your request. The Plan says the annual allowance of $2,750 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 Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the annual allowance of $2,750 has 
been exceeded. The record shows that the Plan paid $2,004 for dental service received on March 11, 2021. The 
record shows that the Plan paid $748 for dental services received on the date of service in this case. $2,004 + 
$748 = $2,750. The Evidence of Coverage clearly states that you are responsible for any amount over the 
allowance. Therefore, we decided that the Plan does not have to pay an additional amount for the consultation 
(D9310), therapeutic parenteral drug (D9610), extractions (D7140 x 10), and surgical extractions (D7210 x 7) 
provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second unit of the initial observation care (99220) 
provided on April 24, 2021. 
 
You asked the Plan to pay for the second unit of code 99220. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 99220 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the 
second unit of code 99220 have not been met. Therefore, we decided that the Plan does not have to pay for the 
second unit of the initial observation care (99220) provided on April 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on 
March 4, 2021, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this testing should be 
covered. The Plan denied your request. The Plan says the drug testing was covered, but the specimen validity 
testing is not separately paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
We looked at the file and Medicare rules. We find that this code is used to represent specimen validity testing 
which is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
unspecified mass spectrometry testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the unspecified mass spectrometry testing provided on March 4, 2021, billed with code 83789.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the $35 copayment for the telephone evaluations. We decided that the 
Plan does not have to waive the $5 copayment for each Medicare-covered primary care provider visit.  
 
You asked the Plan to waive the $35 copayment for the telephone evaluations. You say that you were not 
aware you would be charged two copays. The Plan says that the copayment applied is correct. 
 
We decided that the Plan has to waive the $35 copayment for each Medicare-covered specialist visit.  
 
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 $5 
copayment for each Medicare-covered primary care provider visit. The servicing provider is not a specialist; 
therefore, the specialist copayment does not apply to this claim. 
 
The Plan says that you must pay a $35 copayment for office visit. Based on the Plan contract, however, you 
cannot be asked to pay more than a $5 copayment for this office visit. Therefore, we decided that the Plan has 
to reduce the copayment for this office visit from $35 to $5. 
 
We also decided that the Plan does not have to waive the $5 copayment for each Medicare-covered 
primary care provider visit. 
 
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 $5 
copayment for each Medicare-covered primary care provider visit. Therefore, we decided that the Plan does not 
have to waive the $5 copayment for each Medicare-covered primary care provider visit. 
 
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 a group 3 power wheelchair (single power option) with 
an expandable controller system (E2310, E2377, E2313) and calf pads/foot bracket (E0995, K0108). 
 
You asked the Plan to pre-approve a group 3 power wheelchair (single power option) with an expandable 
controller system and calf pads/foot bracket. You say that the requested items are medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the items at issue. 
 
The Plan follows Medicare rules. The rules state that Medicare will cover a Power Mobility Device (PMD) 
(i.e., power wheelchair or scooter) for a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such as 
toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the 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 a group 3 power wheelchair (single 
power option) with an expandable controller system. Our reviewer says that a group 3 power wheelchair (single 
power option) with an expandable controller system is not medically necessary. Our physician reviewer found 
records do not document the patient is high risk for skin breakdown has lower extremity muscle spasticity or 
requires bladder catherization to meet criteria for the power tilt. Provided records document that the patient has 
adequate upper extremity strength and function to operate the wheelchairs power options with their own 
switches. The patient appears to meet criteria for a group 3 power wheelchair with no power option but not a 
chair with a single power option. 
 
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 group 3 power wheelchair (single power option) with an expandable 
controller system have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 
3 power wheelchair (single power option) with an expandable controller system (E2310, E2377, E2313) and 
calf pads/foot bracket (E0995, K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a basket for a walker. 
 
You asked the Plan to pre-approve the basket. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
 
 
 
 
 
 
 
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a basket for a walker.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-syn (J7328). 
 
You asked the Plan to pre-approve Gel-syn. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Gel-syn. Our reviewer says that the 
requested use of Gel-syn is not supported. Our physician reviewer found the submitted medical records 
indicates that the enrollee has had improvement with conservative treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-syn have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-syn (J7328).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a continuous glucose monitor. 
 
You asked the Plan to pre-approve supplies for a continuous glucose monitor. You say that you have been 
using these sensors for five years. The Plan denied your request. The Plan says you do not meet Medicare 
criteria for separate coverage of these supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a 
therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).   
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of supplies for a continuous glucose monitor have not been met. Specifically, the requested CGM 
device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by 
Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve supplies for a 
continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Opdivo and Vectibix. 
 
You asked the Plan to pre-approve Opdivo and Vectibix. You say that the medication is 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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Opdivo and Vectibix. Our reviewer 
says that the medication is not medically necessary. Our physician reviewer found the review has determined 
that the documentation does not support that the Opdivo (nivolumab) and Vectibix (panitumumab), is 
medically reasonable and necessary for the enrollee. The documentation does not support that the Opdivo 
(nivolumab) and Vectibix (panitumumab), is safe and effective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo and Vectibix have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Opdivo and Vectibix.
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 this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for 
COViD-19. The enrollee was intubated/ventilated and subsequently received a tracheotomy and feeding 
tube. The enrollee remains on a ventilator with poor neurologic status. It is unclear whether ventilator liberation 
and eventual decannulation are achievable. There is no evidence that the enrollee requires services that are not 
currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no 
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such 
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for 
any ongoing long term care needs.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and topical application of 
fluoride varnish (D1206) provided November 12, 2021. 
 
You asked the Plan to pay for the dental cleaning and fluoride varnish. You say that you have unique medical 
circumstances that require additional dental care and would like an exception to be made. The Plan denied your 
request. The Plan says you have exceeded the frequency limit for these services 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental 
cleaning and fluoride varnish twice per plan year.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that dental cleanings and 
fluoride varnish were previously covered on March 2, 2021, and July 7, 2021.  Based on this information, we decided that the Plan's frequency limits for coverage of the dental cleaning and fluoride varnish have been exceeded. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and topical application of fluoride varnish (D1206) provided November 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the full cast high noble metal crown (D2790) provided on 
September 24, 2021. 
 
You asked the Plan to pay for the dental service. You say that this service should be covered. You also say that 
the previous crown was not properly seated. The Plan denied your request. The Plan says crowns are covered 
once in a 5 year period. The Plan says that the frequency limit has been exceeded. The Plan also says that the 
last crown for this tooth was performed on February 7, 2019. 
 
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 and crowns are listed as covered, the frequency limit of 1 per tooth in a 5 year period has been exceeded. Therefore, we decided that the Plan does 
not have to pay for the full cast high noble metal crown (D2790) provided on September 24, 2021.