Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that prior to your appointment the provider's office 
contacted your plan to confirm your coverage. The Plan denied your request. The Plan says the dental services 
were received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on April 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided 
from April 8, 2021, to May 6, 2021. 
 You asked the Plan to pay an additional amount for the inpatient care. You say that the services were billed 
correctly. The Plan denied your request. The Plan says the records do not support the billing of secondary 
diagnosis code, I21.A1. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with secondary diagnosis code, I21.A1, defined as 
Myocardial infarction type 2. 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 an additional amount 
for the inpatient care. Our reviewer says that the billing of the secondary diagnosis code, I21.A1, is not 
supported. Our physician reviewer found there is no evidence of a repetition of the Troponin levels during 
admission. Though the reviewer found that the provider documented acute myocardial infarction, type II, 
reasonable support within the health record is not present for this diagnosis. Therefore, the review has 
determined that the provided documentation did not support the billing of secondary diagnosis code, I21.A1, 
Myocardial infarction type 2.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
an additional amount for the inpatient hospital care provided from April 8, 2021, to May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 21, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A56853. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on February 21, 2022.
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 
15, 2022. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be 
responsible to pay this. 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 15, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no recent record of physical therapy or chiropractic care. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of any recent inability to tolerate non-invasive/conservative care or medical documentation of 
failure to respond to four (4) weeks of non-invasive/conservative care/physical therapy. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of these services. 
 
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 an epidural steroid injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient care provided on December 
21, 2021, to December 24, 2021. 
 
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford 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 $275 
copayment for inpatient hospital care. 
 
 
 
 
 
 
 You have been asked to pay a $275 copayment for the inpatient care. This item/service falls within the 
inpatient hospital 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. The file shows that you were in the hospital from December 21, 2021, to December 24, 
2021. Since there is no copayment on the discharge date, you have been asked to pay $275 per day for 3 days 
of inpatient care, for a total of $825. Therefore, we decided that the Plan does not have to waive the copayment 
for the inpatient care provided on December 21, 2021, to December 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthosis. 
 
You asked the Plan to pre-approve the MyoPro Motion G orthosis. You say that this item is medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is 
considered 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 the MyoPro Motion G orthosis. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, 
professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not 
in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro 
Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for 
long term use. There is insufficient evidence in the literature that this device will increase participation in 
bimanual activities. 
 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 MyoPro Motion G orthosis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the MyoPro Motion G orthosis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) coded 74176 provided on 
March 16, 2022. 
 
You asked the Plan to pay for the CT. You say that you disagree with the Plan's 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. 
 
In this case, the CPT Code Manual definition of code 74176 is computed tomography, abdomen and pelvis; 
without contrast material. 
 
 
 We find that CPT code 74176 is not supported in the medical record. Specifically, the documentation does not 
support that this service was completed. Per the radiology report, the services were compared to CT renal stone 
protocol on February 6, 2022. Based on this information, we decided that Medicare rules for coverage of the 
CT have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography 
(CT) coded 74176 provided on March 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient spinal procedure provided on 
April 25, 2022. 
 
You asked the Plan to waive the copayment for an outpatient spinal procedure. You say that you are worse now 
than you were before this procedure, you have no answers, and have to have the procedure redone. 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 $325 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $325 copayment for an outpatient spinal procedure. This item/service falls 
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 outpatient spinal procedure provided on 
April 25, 2022. 
 
Maximus read your letter and knows that you may have a quality of care concern. Maximus cannot address 
quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement 
Organization for further review.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Ultraviolet light therapy system panel for the 
enrollee. 
 
You asked the Plan to pre-approve an Ultraviolet light therapy system panel. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not have the diagnosis of 
intractable psoriasis. 
 
The Plan must follow Medicare rules. Medicare rules say that a home ultraviolet phototherapy system is for 
patients with generalized intractable psoriasis. 
 
We looked at the file and Medicare rules. In this case, the enrollee does not have a diagnosis of generalized 
intractable psoriasis. Based on this information, we decided that Medicare rules for coverage of an Ultraviolet 
light therapy system panel have not been met. Therefore, we decided that the Plan does not have to pre-approve 
an Ultraviolet light therapy system panel for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on 
September 09, 2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you should not be 
charged anything additional. 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 $325 
copayment for in-network outpatient hospital services. 
 
 
 
 
 
 
 You have been asked to pay a $325 copayment for the outpatient surgery services. This item/service falls 
within the in-network outpatient hospital 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 
copayment for the outpatient surgery services provided on September 09, 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 admission to a LTACH is medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria 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 medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be recommended. 
 
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 a Freestyle Libre continuous glucose monitor (CGM) 
and supplies (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. You say that the requested CGM and 
supplies are medically necessary due to other general symptoms and signs. The Plan denied your request. The 
Plan says you do not meet coverage criteria for the requested CGM and supplies. The Plan also says as an 
alternative, you can request a glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle 
Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre continuous glucose monitor (CGM) and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 26, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
June 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing (0037U) provided 
February 21, 2022. 
 
You asked the Plan to pay for the F1CDx testing. You say that this service should be covered by the Plan. The 
Plan denied your request. The Plan says Medicare billing criteria were not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes, modifiers and in this case an identifier, based on the 
Medicare LCD guidelines applicable to the service. Medicare requires claims for this type of testing to be 
billed with a unique test identifier. 
 
We looked at the file and Medicare rules. Based on L35025, this requirement is applicable as the claim shows 
the lab test was rendered in North Carolina. The LCD indicates all tests billed within this jurisdiction are required to be billed with a Unique Test Identifier. We find do not find this identifier was billed on the claim. 
Based on this information, we decided that Medicare rules for coverage of the F1CDx testing have not been 
met. Therefore, we decided that the Plan does not have to pay for the FoundationOne CDx (F1CDx) testing 
(0037U) provided February 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery back-up device for a continuous positive air 
pressure (CPAP) machine (A9270). 
 
You asked the Plan to pre-approve a battery back-up. You say that in the sector where you live, the power goes 
out and the outages last for hours, either day or night. You have a CPAP machine, and you need this back up 
battery. The Plan denied your request. The Plan says the external batteries or any other source of alternate 
energy area not considered by Medicare medical equipment, nor for beneficiaries who live in an area of federal 
emergency declared or area of major disaster, nor even if are used to give energy to a medical equipment as are 
the machine to treat sleep apnea with CPAP. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
 
 We looked at the file and Medicare rules. Specifically, back up batteries for a CPAP machine or any other 
source of alternate energy are not considered medical equipment and therefore, not a covered benefit with 
Medicare or your Plan. Based on this information, we decided that Medicare rules for coverage of a battery 
back-up have not been met. Therefore, we decided that the Plan does not have to pre-approve a battery back-up 
device for a continuous positive air pressure (CPAP) machine (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) receiver (K0554). 
 
You asked the Plan to pre-approve a CGM receiver. You say that submitted medical records confirm the 
medical necessity of the requested receiver. The Plan denied your request. The Plan says you do not meet 
coverage criteria for the requested CGM receiver. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) receiver (K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (99153) provided on April 13, 2022. 
 
You asked the Plan to pay for the sedation services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid 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. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this service has a 
professional component / technical component indicator of 3. The service was billed in a hospital setting. This 
service is not separately payable. Based on this information, we decided that Medicare rules for coverage of the 
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation 
services (99153) provided on April 13, 2022.