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

We decided that the Plan does not have to pay for intermittent limb compression device (E0675) and segmental 
gradient pressure pneumatic appliance, half leg (E0673) provided March 16, 2021. 
 
You asked the Plan to pay for intermittent limb compression device and appliance. You say that please make 
this part of the enrollee's covered services for safe and effective surgical procedures. The Plan denied your 
request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. 

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. 
 
In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service 
would have been included under the facility claim. Payment for this service is the responsibility of the facility 
or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for intermittent 
limb compression device (E0675) and segmental gradient pressure pneumatic appliance, half leg (E0673) 
provided March 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on February 18, 2021.

You asked the Plan to waive the copayment for an EGD. You say that you were told that you would not owe a copayment and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

The medical records show that you received an EGD on February 18, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $340.93, which is less than the $400 copayment.

You have been asked to pay the total copayment amount of $340.93 for an EGD. An EGD 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 EGD provided on February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray you had on February 12, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that there is not supposed to be a copayment for this service. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for basic radiological services. You have been asked to pay a $15 copayment for the x-ray. The x-ray falls within the basic radiological 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 x-ray you had on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the local excision of malignant tumor of stomach coded as 
43611 provided on February 17, 2021. 
 
You asked the Plan to pay for the local excision of malignant tumor of stomach. You say that you would like 
this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the medical 
records do not support the service billed. Specifically, the billed code is inclusive to another code already paid 
by the Plan. 
 
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 43611 is excision, local; malignant tumor of stomach. 
 
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 local excision of malignant tumor of stomach. Our 
reviewer says that the medical records do not support the services billed. Our reviewer found the medical 
records provided do not include sufficient documentation to validate that 43611 was performed as a distinct, 
separate service from 49204 performed by the same provider on the same date of service and during the same 
operative session. 43611 is inclusive to 49204, therefore, not additional reimbursement is separately payable. 
 
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 local excision of malignant tumor of stomach have not been met. Therefore, 
we decided that the Plan does not have to pay for the local excision of malignant tumor of stomach coded as 
43611 provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
May 19, 2021, to May 26, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
increase in charges and want a lower rate. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 19, 2021, to May 26, 2021. Therefore, you are responsible to pay 
a $325 copayment for days 1-5 (May 19, 2021, to May 23, 2021). The total amount you owe is: $325 
(copayment) x 5 (inpatient days) = $1,625.  
 
You have been asked to pay the total copayment amount of $1,625 for an inpatient hospital stay. An inpatient 
hospital stay 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. Therefore, we decided that 
the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 19, 2021, to 
May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-operated vehicle (K0800).

You asked the Plan to pre-approve a power-operated vehicle. You say that this device is necessary because you
cannot walk too much. The Plan denied your request. The Plan says this device is not covered for outdoor use.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a power-operated vehicle (K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network (OON) laminectomy at the in-
network benefit level. 
 
You asked the Plan to pre-approve the OON laminectomy at the in-network benefit level. You say that the 
services in dispute are medically necessary. The Plan denied your request. The Plan says there are in network 
providers who can supply the services needed. The Plan says that there are not network inadequacies. 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). The rules also say that a Medicare plan may restrict members to a 
network of providers as long as medically necessary covered care is accessible and available through this 
network. Your contract with the Plan clearly says that you must pay one set of cost-sharing amounts for in 
network providers, and another set of cost-sharing amounts for out of network providers.  
 
The provider you are requesting to receive the laminectomy from is not contracted with the Plan and is 
considered OON. You have been told that an OON set of benefits will be applied to the requested OON 
laminectomy. There is no evidence that the medically necessary care being requested is unavailable or 
inadequate through the Plan's network of providers. This means that you have been quoted the correct set of 
benefits for the OON services 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 pre-
approve an out of network (OON) laminectomy at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64624).

You asked the Plan to pre-approve a genicular nerve block. You say that you are requesting an appeal because
the enrollee needs this injection done because the enrollee has localized left knee pain for more than 3 months
and difficulty doing daily activities. The Plan denied your request. The Plan says this service is considered
experimental as there is no medical proof that genicular nerve blocks help with knee pain and there are no
shown improved long term health outcomes.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan does not have to
pre-approve a genicular nerve block (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria has not been met.

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 does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

.We decided that the Plan does not have to waive the copayment for the radiation therapy provided from January 21, 2021, to February 4, 2021.
You asked the Plan to waive the copayment for the radiation therapy. You say that you are being overcharged. The Plan denied your request. The Plan says you have been asked to pay 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 in-network Medicare-covered radiation therapy service. You have been asked to pay a $50 copayment for the radiation therapy on each date of service. ($50 x 5 dates of service = $250). The radiation therapy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.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 radiation therapy provided, from January 21, 2021, to February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on April 8, 2021.
You asked the Plan to pay for the periodontal maintenance. You say that the services should be covered. The Plan denied your request. The Plan says there is no coverage when services are rendered by an out-of-network provider.
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 the periodontal maintenance (D4910), provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

ided that the Plan does not have to pre-approve a walk-in bathtub (99998).
You asked the Plan to pre-approve a walk-in bathtub. You say that you feel that it is medically necessary based on the enrollee's general symptoms and signs. The Plan denied your request. The Plan says this is not covered because a walk-in bathtub is considered a convenience item that is primarily hygienic in nature.
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 a walk-in bathtub (99998).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular
partial denture (D5214).
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that your initial
partials were not made correctly which is why you need new ones. The Plan denied your request. The Plan says
these services are allowed one time every 60 months. The Plan also says that you have received these services
less than 60 months ago. dicare 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, maxillary and mandibular partial
dentures are each limited to once per 60 months. The record shows that you received partials on March 21,
2019 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been
exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture
(D5213) and a mandibular partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete upper denture (D5110) and a partial lower denture (D5214).
You asked the Plan to pay for the dentures. You say that your previous dentures were made by a different provider and they do not fit/work properly and your previous provider did not fix them. The Plan denied your request. The Plan says dentures can only be covered once every five years. The Plan previously paid for you to have dentures in May 2018, which is less than five years (60 months) before the date in question. Therefore, these services will not be covered.
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 denture is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous set of dentures that were paid for by the Plan less than five years ago.
Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a partial
lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based fillings (D2335, D2391, D2332) provided on
July 15, 2021.
You asked the Plan to pay for dental fillings. You say that these services were necessary. The Plan denied your
request. The Plan says these services are not covered by your dental benefit.
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 resinbased
fillings (D2335, D2391, D2332) provided on July 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) admission and care.
You asked the Plan to pre-approve SNF admission and care. You say that the service is medically necessary.
The Plan denied your request. The Plan says that the service is not medically necessary and reasonable.
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 admission and care. Our reviewer
says that the service is medically necessary. Our physician reviewer found daily skilled services are required to
establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care
needs at this point, as a practical matter, cannot be provided at a lower level of care.
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 admission and care have been met. Specifically, the enrollee does require
daily skilled nursing services that cannot be obtained at a lower level of care. The Plan must continue coverage
for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has
been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to preapprove
skilled nursing facility (SNF) admission and care.
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 pay for the pleural drainage, percutaneous, with insertion of
indwelling catheter coded as 32557 provided on March 2, 2021.
You asked the Plan to pay for the pleural drainage, percutaneous, with insertion of indwelling catheter. You say
that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan
says the services are included in payment under the global surgery package.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. The rules also say that there is a postoperative
period of 10 days for some minor surgeries that does not allow separate payment for postoperative visits or
services within 10 days of the surgery.
We find that CPT code 32557 is not separately payable. Specifically, this code is considered paid under the
same global surgery package of the minor surgery 36558 received on February 25, 2021. Based on this
information, we decided that Medicare rules for coverage of the pleural drainage, percutaneous, with insertion
of indwelling catheter have not been met. Therefore, we decided that the Plan does not have to pay for the
pleural drainage, percutaneous, with insertion of indwelling catheter coded as 32557 provided on March 2,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional physical therapy (PT) provided on March 4, 2021.
You asked the Plan to pay for additional PT. You say that the PT visit is medically necessary. The Plan denied
your request. The Plan says the PT visit is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
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 pay for additional PT. Our reviewer says that skilled
services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found that the additional requested therapy is not generally accepted as
specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The
enrollee has had prior extensive therapy and the records do not demonstrate that the unique skills of a
professional therapist were required to safely and effectively provide treatment, that the services could have
been safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The
enrollee was already instructed in a home exercise program and his functional deficits were not so significant
that he required therapy on March 4, 2021. The requested services were not part of a maintenance program, and
the specialized skill, knowledge and judgment of a qualified therapist were not required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT have not been met. Therefore, we decided that the Plan does not
have to pay for additional PT provided on March 4, 2021.