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

We decided that the Plan does not have to pre-approve a crutch substitute with wheels (E0118).
You asked the Plan to pre-approve a crutch substitute with wheels. You say that this is medically necessary. The Plan denied your request. The Plan says the requested item at issue in this case is experimental/investigational.
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 a crutch substitute with wheels. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate why you are unable to use standard crutches. There is no evidence that this device is safer and more effective than a standard assistive device for ambulation such as regular crutches. 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 crutch substitute with wheels have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute with wheels (E0118).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve Euflexxa injections. You say that the injections are medically necessary.
The Plan denied your request. The Plan says there is no documentation showing that the enrollee has tried
physical therapy, or oral pain medication.
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 Euflexxa injections. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has failed steroid injections but has not attempted oral analgesics or
conservative non-pharmacologic therapies. The record provided does not establish the medical necessity and
reasonableness, as defined by Medicare rules, of the requested service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve Euflexxa injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy services provided from
January 4, 2021, to January 27, 2021.
You asked the Plan to waive the copayments for the radiation therapy services. You say that you were informed
by the provided that the services would be covered in full. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 $50
copayment for each radiation therapy service visit.
The file shows that you had a total of 7 visits from January 4, 2021, to January 27, 2021. Therefore, you have
been asked to pay $350 for the radiation therapy services ($50 copayment x 7 visits = $350). The radiation
therapy services fall within the 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 copayments for radiation therapy services provided from
January 4, 2021, to January 27, 2021.
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 require approximately twenty-five (25) days of daily physician care or specialized nursing care that is only available in an LTACH. The Plan states you are recovering from an acute illness; however, you will need continued care, including respiratory care, dialysis and therapy services. The Plan states you can safely receive this care in another setting, such as your current acute care facility or a skilled nursing facility (SNF).

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 you appear to be improving and only requires short-term additional acute care services that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered soon when treatment has completed.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76775 provided on May 24, 2021.
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 76775 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited. We find that CPT code 76775 is not supported in the medical record. Specifically, this code was billed with a primary diagnosis of B96.20 (Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere).
This code is a supplementary or additional code that should not be billed as the appropriate primary or first-listed diagnosis. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76775 provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 6, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the office visit. You say that you received a letter from the payer indicating that
an authorization for the office visit was not required. The Plan denied your request. The Plan says no prior
authorization was obtained.
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 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 the office visit provided on July 6, 2021, by an
out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that this acute level of rehabilitation is too aggressive for the enrollee, and they continue to miss time with therapy due to nausea, multiple recent episodes of emesis, and increased pain. You state the enrollee is only four (4) weeks post-op can still benefit from rehabilitation at a lower intensity level, which would fit their needs best at this point. The Plan denied your request.
The Plan says the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF) and all the services the enrollee needs is offered at the IRF. The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.
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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in at a SNF level. As a practical matter, this enrollee does not require transfer from an inpatient acute rehabilitation facility to a SNF setting. The enrollee requires continued management in an IRF for their emesis and for pain management. The enrollee is making progress in therapy and does not require a transfer to a SNF. The enrollee's medical and therapy needs can safely and effectively be managed by their current setting until they are ready for a home or community discharge. 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 SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy services provided from
January 6, 2021, to October 4, 2021.
You asked the Plan to waive the copayments for the physical therapy services. You say that you were not made
aware of any copayments when you had your appointments. The Plan denied your request. The Plan says you
have been charged the correct cost sharing amount.
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 $35 copayment for each physical therapy visit.
The file shows you had a total of 22 physical therapy visits from January 6, 2021, to October 4, 2021.
Therefore, you have been asked to pay $770 for the physical therapy services ($35 copayment x 22 visits =
$770). The physical therapy services fall within the Outpatient Rehabilitation Services benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayments for physical therapy services provided from January 6, 2021,
to October 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medication assisted treatment, methadone (G2067) provided on July 5, 2021 to July 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for medication assisted treatment. You say that you appreciate consideration so that you may continue to provide your patients with the medically needed services to overcome their addiction. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 medication assisted treatment, methadone (G2067) provided on July 5, 2021 to July 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services (0012M) provided January 8, 2021.
You asked the Plan to pre-approve the lab services. You say that the service was medically necessary. The Plan
denied your request. The Plan says this test is non-covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for CPT
codes 0012M and 0013M for CxBladder.
We looked at the file and Medicare rules. CPT code 0012M was billed. This service is non-covered. Based on
this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore,
we decided that the Plan does not have to pre-approve lab services (0012M) provided January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot care services provided to you on September 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. 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 foot care services provided to you on September 1, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services of home health aide (HHA) (G0156).
You asked the Plan to pre-approve the HHA services. The Plan denied your request. The Plan says the enrollee
does not meet the guidelines for the requested service which does not appear medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
We 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 HHA services. Our reviewer says
that the requested HHA services are not medically necessary, reasonable or coverable. Our physician reviewer
found a HHA is not shown to be medically necessary to aide in the treatment of illness or injury.
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 HHA services have not been met. Therefore, we decided that the Plan does
not have to pre-approve services of home health aide (HHA) (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for caries risk assessment and documentation, with a finding of
high risk (D0603) oral hygiene instruction (D1330) provided from November 20, 2019, to January 7, 2020.

You asked the Plan to pay for the dental services. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says these services are not covered under the Plan
benefits.

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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for caries risk
assessment and documentation, with a finding of high risk (D0603) oral hygiene instruction (D1330) provided
from November 20, 2019, to January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the core buildup including any pins when
required (D2950) root canal (D3310) post removal (D2955) retreatment of previous root canal therapy (D3346)
provided on September 22, 2021.
You asked the Plan to waive the coinsurance for the dental services. You say that when you went for the
procedure you were given an estimate of $3635 and that your part was $2428.50. You were informed on
10/22/21 that you owed an additional $598.10, and you have paid the additional bill. The Plan denied your
request. The Plan says the correct cost share was applied per the Evidence of Coverage.
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 60%
coinsurance for out of network major restorative care after the $150 deductible is met.
You have been asked to pay $598.10 for the dental services. The services fall within the Dental services benefit
category. Page 113 of the Plan contract says that you may incur a higher cost share when going out of network
if the dentist you see charges more than the allowed amount. If this happens, you may receive a bill for the
difference between the charged amount and the allowed amount paid by the Plan. 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 core buildup including any pins when required (D2950) root canal (D3310)
post removal (D2955) retreatment of previous root canal therapy (D3346) provided on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851, L2397) provided on October 4,
2021.
You asked the Plan to pay for a knee orthosis. You say that this is supported in the records. The Plan denied
your request. The Plan says this was not billed with appropriate diagnosis codes.
The Plan must follow Medicare rules. Medicare rules say that some diagnosis codes indicate laterality,
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the
condition is bilateral, assign separate codes for both the left and right side.
We looked at the file and Medicare rules. The items at issue were billed with both code M17.11, unilateral
primary osteoarthritis, right knee, and M17.0, bilateral primary osteoarthritis of knee. It is not appropriate to
report both a unilateral and a bilateral diagnosis code for the same condition. Based on this information, we
decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for a knee orthosis (L1851, L2397) provided on October 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an emergency room visit (99281)
provided on September 13, 2021.

You asked the Plan to waive the cost-sharing for the emergency room visit. You say that the services should be
covered as you feel like you shouldn't have to pay for only having your vitals taken. The Plan denied your
request. The Plan says the cost-sharing applied correctly based on the services provided.

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. Based on your contract with the
Plan, the cost-sharing for emergency care is only waived if you are admitted into the hospital within 24 hours
for the same condition. 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 cost-sharing for an emergency room visit
(99281) provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #'s 3 and 5.
You asked the Plan to pre-approve the pontic and retainer crowns. The Plan denied your request. The Plan says the documentation submitted does not demonstrate the required criteria have been met at this time.
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 pontic and retainer crowns when the services are medically necessary and reasonable. 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 pontic and retainer crowns. Our reviewer says that the criteria for coverage for a fixed bridge replacing tooth #4 have not been met. Our physician reviewer found according to the rules for coverage, an abutment tooth for a fixed bridge must meet the criteria for a crown restoration (significant coronal breakdown due to caries or fracture). Our reviewer also found that in this case the abutment teeth (#'s 3 and 5) have crowns in place that do not appear to need replacing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #4 and retainer crowns (D6740) for tooth #'s 3 and 5.