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

 
We decided that the Plan does not have to pre-approve a bedside commode. 
 
You asked the Plan to pre-approve a bedside commode. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested bedside 
commode. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Therefore, 
we decided that the Plan does not have to pre-approve a bedside commode.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a perirectal spacer for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the research shows that the application of 
SpaceOAR was well tolerated with a 99% technical success rate and resulted in rectum and penile bulb 
radiation dose reduction, less acute pain, lower rates of rectal toxicity, and improved bowel and urinary quality 
of life scores from 6 months onward. The Plan denied your request. The Plan says the medical records did not 
show that the Enrollee's prostate cancer is grade T1 or T2 and has low or favorable intermediate risk. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while the urologist's clinic note describes this patient as having high risk disease, National 
Comprehensive Care Network (NCCN) guidelines specify high risk as being T3 or higher (this patient has T2 
disease), Grade group 4-5 (this patient has grade group 3), or prostate specific antigen (PSA) more than 20. 
This patient has unfavorable intermediate risk disease due to higher risk factors of 2+ intermediate risk factors, 
grade group 3, and 11/12 cores positive. The criteria are explicit in which risks groups are covered (and only 
low-risk and favorable intermediate risk disease is covered) and also the need to use SpaceOAR when other 
techniques would be insufficient which is not shown on this case. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a perirectal spacer for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 20, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 20, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on June 12, 
2022. 
 
You asked the Plan to waive the copayment for urgent care services. 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 $65 
copayment for urgently needed services. 
 
You have been asked to pay a $65 copayment for urgent care services. This item/service falls within the 
urgently needed 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 urgent care 
services provided on June 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided on 
January 08, 2021, to January 31, 2021. 
 
You asked the Plan to waive the copayment for a skilled nursing facility stay. 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 $552 
copayment for skilled nursing facility (SNF) care. 
 
You have been asked to pay a $552 copayment for a skilled nursing facility stay. This item/service falls within 
the skilled nursing facility (SNF) 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 a 
skilled nursing facility stay provided on January 08, 2021, to January 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve panniculectomy services. 
 You asked the Plan to pre-approve panniculectomy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
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 panniculectomy services. Our reviewer 
says that the documentation does not support that the requested services are medically reasonable or necessary. 
Our reviewer found the enrollee has a pannus with intermittent intertrigo. The record indicates that the enrollee 
is attempting to lose weight but does not indicate the existence of any functional limitations caused by the 
pannus. The record provided does not establish the medical necessity and reasonableness, as defined by 
Medicare rules, of the requested service. Therefore, the enrollee does not meet criteria for the requested 
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 panniculectomy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve panniculectomy services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on May 17, 2022. 
 
You asked the Plan to waive the copayment for an EKG. You say that there shouldn't be a copayment for this 
service. 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 $50 
copayment for diagnostic procedure or test in a network doctors office.  
 
You have been asked to pay $30.32, which is less than the original copayment of $50 for an EKG. This 
item/service falls within the diagnostic procedure or test in a network doctors office 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 EKG provided on May 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 30, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service May 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for a procedure and spinal cord stimulator provided 
on May 20, 2022. 
 
You asked the Plan to waive the cost for a procedure and spinal cord stimulator. You say that you were only 
told of the copayment for the procedure, not anything else. 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 enrollees must pay a 
$75 copayment for outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers, and a 20% coinsurance for prosthetic devices and related supplies. 
 You have been asked to pay a $75 copayment for a procedure and a $1700 coinsurance for a spinal cord 
stimulator (this is less than the 20% coinsurance). This item/service falls within the outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers and prosthetic 
devices and related 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 cost for a procedure and 
spinal cord stimulator provided on May 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the duplex scan (ultrasound) of extracranial 
arteries provided on May 20, 2022. 
 
You asked the Plan to waive the copayment for the duplex scan (ultrasound) of extracranial arteries. You say 
that you are on a fixed income and 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 $150 
copayment for radiological diagnostic services, not including x-rays. 
 
You have been asked to pay a $150 copayment for the duplex scan (ultrasound) of extracranial arteries. This 
item/service falls within the radiological diagnostic services, not including x-rays 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 duplex scan (ultrasound) of extracranial arteries provided on May 
20, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve breast reduction. 
 You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that medical treatment and/or physical interventions have not 
adequately alleviated symptoms. Rashes have responded to over the counter hydrocortisone. The enrollee 
sometimes takes over-the-counter ibuprofen when the pain becomes very severe. The enrollee has not been to a 
physical therapist or chiropractor. The documentation does not support that the requested surgery is medically 
reasonable and necessary at this time. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve breast reduction.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from February 21, 2022, to February 28, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was not coded correctly. 
 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 the denied services are not supported in the medical record. Specifically, there is no evidence of a 
valid HIPPS code being used on the claim. 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 skilled 
nursing facility (SNF) services provided to the enrollee from February 21, 2022, to February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for outpatient surgery provided on June 20, 
2022. 
 
You asked the Plan to reduce the copayment for outpatient surgery. You say that you feel this should be an 
emergency room visit copayment rather than an outpatient hospital 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 $350 
copayment for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for outpatient surgery. This item/service falls within the 
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 reduce the copayment for outpatient 
surgery provided on June 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a facility-based polysomnography (95810). 
 You asked the Plan to pre-approve the services. You say that an in-lab study is medically necessary. The Plan 
denied your request. The Plan says using a home sleep study is appropriate for the diagnosis of sleep apnea. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the documentation does not support that the enrollee in this case has a co-morbidity such as 
congestive heart failure, hypo-ventilation syndrome, moderate to severe pulmonary disease, or neuromuscular 
disease. The case file does not contain persuasive medical evidence justifying the medical necessity for 
additional testing. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a facility-based polysomnography (95810).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bioengineered skin substitute. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is only covered for lower extremity non-healing wounds that have failed to respond 
to standard wound treatment for at least 30 days. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that documentation does not support that a bioengineered skin substitute is medically reasonable and 
necessary for the enrollee in this case. It has not been demonstrated that the wound has failed to respond to 
standard wound treatment for an extended period of time. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a bioengineered skin substitute.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray and follow up provided on April 
15, 2022. 
 
You asked the Plan to waive the copayment for an x-ray and follow up. You say that you have not been 
charged these copayments before and you do not understand why you are getting them now. 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 $15 
copayment for outpatient diagnostic tests and therapeutic services and supplies, and a $35 copayment for 
physician/practitioner services, including doctors office visits ($15 + $35 = $50). 
 
You have been asked to pay a $50 copayment for an x-ray and follow up. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies, and physician/practitioner services, including 
doctors office visits 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 x-ray and follow up provided on April 15, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee pain 
related to osteoarthritis. She has not tried and failed the Plan's required drugs, Durolane, Euflexxa, Supartz, and 
Gelsyn-3. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Trivisc is not reasonable or medically necessary, 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Trivisc.