Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for remove device interrogation provided on July 8, 2022. 
 
You asked the Plan to pay for device evaluation. You say that this treatment was medically necessary and time 
sensitive. The Plan denied your request. The Plan says that this provider is out-of-network with the Plan and 
authorization was not obtained. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 pay for device evaluation. Our reviewer says that 
this service meets criteria for payment. Our physician reviewer found the enrollee could not have foreseen 
requiring this service prior to leaving the Plan's service area. The records indicate that the service was 
medically necessary as it was directly related to an emergency procedure. It would not have been appropriate or 
medically reasonable to delay service until the enrollee returned to the Plan's service area (or up to 6 months). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of device evaluation have been met. Therefore, we decided that the Plan has to pay 
for remove device interrogation provided on July 8, 2022.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty. 
 
You asked the Plan to pre-approve kyphoplasty. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that PVA (Percutaneous Vertebroplasty (PVP) or 
Kyphoplasty (PKP)) is covered when specific criteria is 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 kyphoplasty. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the current back pain also cannot be 
determined to be primarily due to the identified acute or subacute osteoporotic VCF(s). There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the enrollee does not meet the coverage criteria detailed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of kyphoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve kyphoplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia for extensive spine and spinal cord procedures 
coded 00670 provided on May 3, 2022. 
 
You asked the Plan to pay for the anesthesia services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is insufficient 
documentation to corroborate the services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 00670 is anesthesia for extensive spine and spinal cord procedures. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the anesthesia services as billed. Our reviewer says that the 
documentation does not support the CPT code billed. Our reviewer found the medical record does not include 
anesthesia report. Operative report documents, The patient was sedated and intubated without difficulty by the 
anesthesia service. However, an anesthesia procedure report was not included, and correct coding cannot be 
verified. Therefore, the CPT code billed cannot be substantiated. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the anesthesia services as billed have not been met. Therefore, we decided that 
the Plan does not have to pay for the anesthesia for extensive spine and spinal cord procedures coded 00670 
provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an orthopedic pillow. 
 
You asked the Plan to pre-approve an orthopedic pillow. You say that this is necessary for your condition. The 
Plan denied your request. The Plan says this item is not covered by Medicare or the Plan. 
 
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 an orthopedic pillow.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten additional transportation trips. 
 
You asked the Plan to pre-approve ten additional transportation trips. You say that you need transportation to 
the vein center. The Plan denied your request. The Plan says the additional trips are not covered benefits. 
 
 
 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 ten 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. Specifically, the 
requested trips are beyond the ten one-way trips. Therefore, we decided that the Plan does not have to pre-
approve ten additional transportation trips.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on June 
25, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit 
provided on June 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWO) (E0483). 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation device. You say that the item is 
medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has 
cystic fibrosis, bronchiectasis, or a neuromuscular disorder. 
 
The Plan follows Medicare rules. Medicare rules say that a high frequency chest wall oscillation device is 
covered when the enrollee has cystic fibrosis, bronchiectasis, or a neuromuscular disorder. 
 
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 high frequency chest wall oscillation 
devices. Our reviewer says that the item is not medically necessary. Our physician reviewer found the records 
do not show that the enrollee has cystic fibrosis, bronchiectasis, or a neuromuscular disorder. 
 
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 high frequency chest wall oscillation devices have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWO) 
(E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit (99285), and electrocardiogram 
(93010) provided on May 3, 2022. 
 
You asked the Plan to pay for the emergency room services. You say that the enrollee was seen twice on the 
date of service in this case. 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 services at issue were reimbursed 
by the Plan on June 2, 2022. Comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date. Based on this 
information, we decided that the Medicare rules for the emergency room services have not been met. 
Additionally, while the records do support that the enrollee was seen twice on the date of service in this case, 
they also show that the enrollee was seen by different attending physicians for each visit. Therefore, we decided that the Plan does not have to pay for the emergency room visit (99285), and electrocardiogram 
(93010) provided on May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need this item. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for primary care provider visit provided on 
June 29, 2022. 
 
You asked the Plan to waive the copayment for primary care provider visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for in-network physician/practitioner services/primary care provider visit.  
 
You have been asked to pay a $10 copayment for primary care provider visit. This item/service falls within the 
in-network physician/practitioner services/primary care provider 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 copayment for primary care provider visit provided on June 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70543 and A9585 billed for date of service 
June 9, 2022. 
 
You asked the Plan to pay for the billed services. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim. 
 
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 services at issue were reimbursed 
by the Plan on July 11, 2022. A comparison of the two claims shows these are exact duplicates. There is no 
evidence presented to support that the billed services were provided twice on the same date.  Based on this information, we decided that the Medicare rules for the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes 70543 and A9585 billed for date 
of service June 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device 
(E0601). 
 
You asked the Plan to pre-approve a CPAP device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary.  
The Plan follows Medicare rules. Medicare rules say that adherence to therapy is defined as use of PAP greater 
than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during 
the first three (3) months of initial usage. 
 
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 CPAP device. Our reviewer says that 
the item is not medically necessary. Our physician reviewer found there is no record of a face-to-face visit with 
the provider to review CPAP use and benefit, and there is no CPAP usage data.  
 
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 CPAP device have not been met. Specifically, there is no record of a face-to-
face visit with the provider to review CPAP use and benefit, and there is no CPAP usage data to show 
adherence to therapy. Therefore, we decided that the Plan does not have to pre-approve a continuous positive 
airway pressure (CPAP) device (E0601).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve CPAP device. You say that the enrollee is compliant with use of the CPAP 
and needs to continue. The Plan denied your request. The Plan says there is no documentation of compliance 
with use of CPAP 4 hours per night for 70% of nights during a consecutive 30 day period. 
 
The Plan follows Medicare rules. Medicare rules state that continued coverage of a positive airway pressure 
device requires adherence to therapy, defined as use of positive airway pressure 4 or more hours per night on 
70% of nights during a consecutive 30 day period. 
 
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 CPAP device. Our reviewer says that 
the enrollee does not meet the criteria for continued use of the CPAP device. Our physician reviewer found the 
enrollee has a diagnosis of obstructive sleep apnea (OSA). However, there is no documentation of when CPAP 
was started and no device download to document minimum usage requirements have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve Lynch Syndrome tumor screening and PD-L1 testing. 
 
You asked the Plan to pre-approve Lynch Syndrome tumor screening and PD-L1 testing. You say that the 
requested Lynch Syndrome tumor screening and PD-L1 testing are medically necessary. The Plan denied your 
request. The Plan says that the requested Lynch Syndrome tumor screening and PD-L1 testing are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 Lynch Syndrome tumor screening and 
PD-L1 testing. Our reviewer says that the requested Lynch Syndrome tumor screening and PD-L1 testing are 
medically necessary. Our physician reviewer found the development of sophisticated genetic and molecular 
characterization of central nervous system (CNS) neoplasms has shown that histologically similar neoplasms 
can be characterized more accurately for prognosis and in some instances for response to different therapies. 
Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and 
eligibility in clinical trials for CNS neoplasms over the last 10 years and is increasingly becoming a common 
part of standard neuro-oncology management. The NCCN Guidelines recommends molecular profiling to 
identify clinically relevant sub-types to encourage opportunities for clinical trial involvement. There are also 
approved therapies based on certain molecular markers, including those used to identify Lynch Syndrome, as 
well as PD-L1. Given the lack of efficacious treatments available for patients with glioblastoma the use of 
molecular testing such as with Foundation One is reasonable and medically necessary for this enrollee with recurrent glioblastoma. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lynch Syndrome tumor screening and PD-L1 testing have been met. Therefore, 
we decided that the Plan has to pre-approve Lynch Syndrome tumor screening and PD-L1 testing.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2750) upgrade provided on March 4, 
2022. 
 
You asked the Plan to pay more for the upgraded crown. You say that you were charged $1,025 for the crown 
services, but the office did not provide you with a breakdown of what is covered under insurance and what was 
not covered, The Plan denied your request. The Plan says the correct copayment for the crown is $425. The 
Plan also says you were billed $300 for the crown upgrade, which is not a covered benefit. 
 
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 record shows that you agreed to the 
$300 upcharge for the upgraded crown with EMAX materials, and this cannot be refunded to you. Therefore, 
we decided that the Plan does not have to pay more for the crown (D2750) upgrade provided on March 4, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the evaluation and management services provided from August 9, 
2022, to August 10, 2022. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen at the correct facility. 
The Plan denied your request. The Plan says that an inappropriate place of service code was billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
We looked at the file and the rules. The claim was billed with an inpatient rehabilitation facility (IRF) place of 
service code. The Plan has not provided documentation that the enrollee was not at an IRF at the time the 
services were provided. The Plan has not made reasonable and diligent efforts to gather and forward to us 
information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for 
the evaluation and management services provided from August 9, 2022, to August 10, 2022.  
 
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 pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria for admission to a LTACH 
has not been met. 
 
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 that the enrollee appears to be improving but is still unstable and requires short-term 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility.  
 
 
 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.