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

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is being requested for the treatment 
of pneumonia, congestive heart failure (CHF), COPD and chronic respiratory failure. The Plan denied your 
request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be 
delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary for the enrollee. The patient is listed as 
having chronic respiratory failure, although provided documentation does not clearly support this diagnosis.  
 The medical records are insufficient to support the ventilator device as there was no clear abnormal results 
from pulmonary function tests (PFT) or arterial blood gases (ABG) on BiPAP provided or other evidence that 
they had failed BiPAP with average volume-assured pressure support (AVAPS) at home or would be 
inappropriate for such to justify this request. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for a portable home ventilator. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bone growth stimulator you received 
on April 9, 2021. 
 
You asked the Plan to waive the coinsurance for the bone growth stimulator. You say that you cannot afford 
this machine and if you had known the cost, you would not have gotten it. The Plan denied your request. The 
Plan says you were charged this coinsurance correctly 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the bone growth stimulator. The bone growth stimulator falls 
within the durable medical equipment 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 
the bone growth stimulator you received on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
February 1, 2021. 
 You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 items/services at issue in this appeal. 
The Plan did not pre-approve the item/service at issue. The records provided do not support the services billed. 
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 out of network physician services provided to the enrollee on February 1, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950), crown (D2740), and resin filling 
(D2331), provided on April 7, 2021. 
 
You asked the Plan to pay for the core buildup, crown, and resin filling. You say that the services should be 
covered. The Plan denied your request. The Plan says the services are not covered. 
 
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. Specifically, the services are not listed in the Plan's Schedule of Covered Benefits. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950), 
crown (D2740), and resin filling (D2331), provided on April 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 29, 
2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you would like to appeal 
this charge. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services.  
 
 
 
 You have been asked to pay a $250 copayment for the ambulance services. 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 ambulance services provided on May 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that you are requesting 
review of denial of services. The Plan denied your request. The Plan says this provider is four hundred (400) 
miles from your home and your benefit only allows fifty (50) miles. 
 
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.  
 This provider is four hundred (400) miles from your home and your benefit only allows fifty (50) miles. This 
provider would also be considered out of area. The health plan contract says up to sixty (60) one-way trips are 
covered per calendar year (limited to ground transportation only). You are responsible for any costs over the 
trip limit. Trips must be to or from plan-approved locations, such as network physicians, medical facilities and 
pharmacies. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation 
mileage.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incision and drainage of hematoma coded 10140, the 
Destruction of benign lesions coded 17110, the avulsion of nail plate coded 11730, and the debridement of 
nail(s) coded 11721 provided on April 23, 2020 and October 28, 2020. 
 
You asked the Plan to pay for the incision and drainage of hematoma, the Destruction of benign lesions, the 
avulsion of nail plate, and the debridement of nail(s). You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 10140, 17110, 11730, and 11721 are not supported in the medical record. Specifically, 
the medical records submitted do not include documentation for the billed date of services of April 23, 2020 or 
October 28, 2020. This means that codes 10140, 17110, 11730, and 11721 are not supported. Based on this 
information, we decided that Medicare rules for coverage of the incision and drainage of hematoma, the 
Destruction of benign lesions, the avulsion of nail plate, and the debridement of nail(s) have not been met. 
Therefore, we decided that the Plan does not have to pay for the incision and drainage of hematoma coded 
10140, the Destruction of benign lesions coded 17110, the avulsion of nail plate coded 11730, and the 
debridement of nail(s) coded 11721 provided on April 23, 2020 and October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an extensive surgery on the spine provided 
on April 5, 2021. 
 
You asked the Plan to waive the deductible for an extensive surgery on the spine. You say that you told the 
staff not to allow any out-of-network providers to work on you. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible which applies to outpatient surgery and other medical 
services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You had an extensive surgery on the spine at an outpatient hospital facility on April 5, 2021. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible 
to pay the $750 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time an 
extensive surgery on the spine was received on April 5, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for an extensive surgery on the spine provided on April 5, 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 you are not currently receiving proper care and 
require transfer to an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are 
not met. You can receive the care you need in an alternate setting. 
 
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 the complexity of your nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code(s): 22869 and 22870), for the enrollee. 
 
You asked the Plan to pre-approve the surgery. You say that the enrollee has failed conservative approaches to 
treatment at this time. The Plan denied your request. The Plan says unproven and not medically necessary 
procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
 
 
  
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the 
enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. The Plan states the enrollee could receive care 
in another setting. The Plan states they could review alternate settings if requested such as skilled nursing 
facility, outpatient setting or home health 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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for spinal fusion and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
documentation does support a need for physical and/or occupational therapy, there is no documented need for 
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 12, 2021. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation 
submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing 
was taken in an office setting, therefore the POS code 81  indicating an independent lab setting  is not 
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests 
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on 
April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the screening mammography to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the screening mammography. You say that your usual mammogram date 
falls near the end of December. You hate to wait until May to get the Mammogram. The Plan denied your 
request. The Plan says enrollees must receive their medical services from an in-network provider with the 
exception being urgent or emergent services. Preventive screening mammogram is covered once every 12 
months. 
 
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. Preventive screening mammogram is 
covered once every 12 months. The records show that your last screening mammogram was provided 
December 29, 2020. 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 the screening mammography to be provided 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on May 4, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on May 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospital admission. 
 
You asked the Plan to pre-approve an acute inpatient psychiatric hospital admission. You say that the enrollee 
still needs continued care due to ongoing medical situations. The Plan denied your request. The Plan says the 
requested admission to a psychiatric hospital does not meet criteria. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 an acute inpatient psychiatric hospital 
admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in 
question of November 1, 2021, forward as the enrollee was not shown to be a danger to herself or others. The 
enrollee was not showing any delusions, auditory or visual hallucinations and was cooperative/compliant with 
treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an acute inpatient psychiatric hospital admission have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an acute inpatient psychiatric hospital admission.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the abdominal paracentesis procedures 
you had at an outpatient hospital from September 11, 2020, to December 18, 2020. 
 
You asked the Plan to waive the coinsurance for the abdominal paracentesis procedures. You say that you 
believe the cost sharing is too high for this service. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 10% 
coinsurance for outpatient surgery and services at an outpatient hospital facility.  
 
 You have been asked to pay 10% coinsurance for the abdominal paracentesis procedures. The abdominal 
paracentesis procedures fall within the outpatient surgery and services at an outpatient hospital facility 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 the abdominal paracentesis procedures you 
had at an outpatient hospital from September 11, 2020, to December 18, 2020.