Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy (PT) provided on March 4, 2022, by an out-
of-network provider. 
 
You asked the Plan to pay for the PT. You say that there are other enrollees who have this same plan that do 
not require authorization. The Plan denied your request. The Plan says its been determined that these services 
are not urgent or emergent, nor were they approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy (PT) provided on March 4, 2022, 
by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for a diagnostic test provided on March 18, 
2022. 
 
You asked the Plan to lower the copayment for the diagnostic test. You say that the copayment should be lower 
than what was charged. The Plan denied your request. The Plan says the proper copayment was applied for the 
service that was 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 $75 
copayment for In-Network diagnostic procedures and tests, including ultrasounds.  
 
  You have been asked to pay a $75 copayment for the diagnostic test. The diagnostic test falls within Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to lower 
the copayment for a diagnostic test provided on March 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an 
inpatient basis. 
 
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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says your records do not show that you need continued treatments and care that 
can only be given in a hospital setting. The Plan states when you are ready to leave the hospital, you can safely 
receive this care in another setting, such as a skilled nursing facility (SNF) or at home with home health 
services or outpatient setting if appropriate. 
 
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 requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and are able to be furnished safely and effectively only on an 
inpatient basis. 
 
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rental months of the DME (CPT code(s): 
K0738, E1390). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says there is no indication or documentation stating a replacement item(s) is being requested. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The request for additional rental 
months for E1390 and E0738, are not approved. Our records indicate the enrollee received E1390 and E0738 
on June 04, 2019. The enrollee has used 36 months of this services as June 3, 2022. Per CMS Manual System, 
Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, 30.5, Items in this oxygen category are paid on 
a monthly rental basis not to exceed a period of continuous use of 36 months and non-billable during the 
oxygen maintenance period. Authorization for oxygen equipment is limited to 36 monthly rental payments. 
Payment for accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is 
included in the rental allowance. Payment for oxygen contents, (stationary and/or portable) is included in the 
allowance for stationary equipment (E0424, E0439, E1390, E1391). There is no indication or documentation 
stating replacement items are being requested. Therefore, we decided that the Plan does not have to pre-
approve additional rental months of the DME (CPT code(s): K0738, E1390).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Guardant Reveal testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when 
specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has adenocarcinoma of the 
colon and underwent resection and adjuvant chemotherapy. The record indicates that a positron emission 
tomography (PET) scan in March of 2022 revealed no evidence of disease. The record provided is insufficient 
to establish that the enumerated conditions of coverage have been satisfied. The record does not indicate that 
further treatment is contemplated. The testing is therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Guardant Reveal testing.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the power wheelchair and accessories (CPT code(s): K0856, 
E2361, E1002, and E2607). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says that the notes do not show that the enrollee has any of these conditions causing problems 
walking (severe nerve (neurological) disease, muscle disease (myopathy) or bone deformity from birth). 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will be covered if the patient has a mobility 
deficit that impairs their participation in MRADLs, the patients condition cannot be ameliorated by a walker, 
cane or manual wheelchair, and the patient is capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found the enrollee does have diagnosis and mobility impairments that would qualify the enrollee for group 3 
power wheelchair and multiple power options due to inability to pressure relief and difficulty with positioning; 
thus, K0856, E2361, E1002, and E2607 are medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have been met. Therefore, we decided that the Plan has to pre-approve 
the power wheelchair and accessories (CPT code(s): K0856, E2361, E1002, and E2607).  
 
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 waive the coinsurance for specialist visit on March 9, 2022. 
 
You asked the Plan to waive the coinsurance for specialist visit. You say that you expected your insurance to 
cover more than they did. You say you want the plan to fully cover the claim. The Plan denied your request. 
The Plan says coinsurance is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $110 
combined in-network and out-of-network deductible and 15% coinsurance for services obtained from a 
specialist, or under certain circumstances, treatment by a nurse practitioner or physicians assistant or other 
non-physician health care professionals in a specialists office (as permitted under Medicare rules).  
 
  You have been asked to pay $111.35 for the specialist visit.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
March 9, 2022 Specialist visit $118.97 $110 deductible $110.00 
March 9, 2022 Specialist visit 8.97 15% $1.35 
TOTAL    $111.35 
 
The specialist visit falls within the Physician/Practitioner Services, including Doctor's Office Visit 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 specialist visit on March 9, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on March 22, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you should not have a copayment for 
this visit. The Plan denied your request. The Plan says the copayment applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 
copayment for in-network outpatient diagnostic tests.  
 
You have been asked to pay the allowed amount of $148.41, which is less than the $300 copayment for a CT 
scan. A CT scan falls within the In-Network Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on 
March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, foot inserts (L35000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you have foot pain and your podiatrist has 
recommended for you to wear orthotics. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, foot inserts 
(L35000).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on February 
11, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for chiropractic manipulative treatment. You say that the provider and referring 
providers are participating providers with Medicare. The Plan denied your request. The Plan says the enrollee 
went to an out-of-network provider and services were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for chiropractic manipulative treatment provided on 
February 11, 2022, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device with leg appliance 
(CPT code(s): E0652 and E0667). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the enrollee does not have edema that extends to the chest, abdomen, or trunk, 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found the enrollee does not have edema that extends to the chest, abdomen, or trunk as required to meet criteria 
for this specific device. It was not clear in the documentation that there was a full trial of a basic pneumatic 
compression device. Therefore, the records provided do not sufficiently meet the LCD requirements for 
Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device with leg appliance (CPT code(s): E0652 and E0667).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 the 
service is not medically necessary. Our physician reviewer found records do not document the need for 
intravenous medications, new tube feeding, ostomy care, daily complex wound care or respiratory care. There 
is no documentation that daily skilled services are required. Although records document the enrollee is very 
limited functionally, provided records do not document a significant decline in her functional status compared 
to her recent baseline to necessitate daily inpatient skilled therapy services. In addition, the enrollee does not 
appear to be able to cooperate in a meaningful way with therapy and her prognosis for improvement is reported 
to be poor. She does not require the services on an inpatient basis, only in a skilled nursing facility setting. 
Records do not document that services in a long-term care facility on a part time basis are not appropriate in 
this case, if she is able to cooperate in the future. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or 
equal (L5981) and an all-lower extremity prosthesis, multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve all lower extremity prostheses. You say that clinical information has been 
submitted. The Plan denied your request. The Plan says the request for prosthesis with K3 foot and ankle 
exceeds your need and does not meet the Medicare criteria of reasonable and 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 all lower extremity prostheses. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it is standard that after a below-the-knee amputation heals a preparatory 
prefabricated prosthesis is provided to help achieve limb maturation and total contact and to avoid multiple 
socket changes. A level 3 ambulator has the ability or potential for ambulation with variable cadence. Typical 
of the community ambulator who could traverse most environmental barriers and may have vocational, 
therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. 
 In this case, the documentation does not support that you are able to ambulate at a K3 level. The documentation 
indicates that you require a power wheelchair for mobility, and you have had a prolonged course of recovery 
from your most recent amputation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of all lower extremity prostheses have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an all-lower extremity prostheses, flex-walk system or equal (L5981) and 
an all-lower extremity prosthesis, multi-axial rotation unit (L5986).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0861). 
 
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the power wheelchair. Our reviewer 
says that the power wheelchair is not medically necessary. Our physician reviewer found the records show that 
the enrollee's needs could be met by a cane or walker. The records do not include documentation that the 
enrollee can safely operate the power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power wheelchair (K0861).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services billed with codes 73560-26-LT and 73560-26-RT 
for date of service March 11, 2022. 
 
You asked the Plan to pay for codes 73560-26-LT and 73560-26-RT. You say that the enrollee had multiple 
exams on the date in question and the level of service is supported in the medical record. The Plan denied your 
request. The Plan says this claim is a duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on March 23, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for codes 73560-26-LT and 73560-26-RT have 
not been met. Therefore, we decided that the Plan does not have to pay for services billed with codes 73560-26-
LT and 73560-26-RT for date of service March 11, 2022.