Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 26, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal were requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you need help in gaining your strength back. The 
Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do not meet 
the requirements for approval. 
 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 that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode chair. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare does not cover this in these individual circumstances. 
 
The Plan must follow Medicare rules. Medicare rules say that a commode is covered when the beneficiary is 
physically incapable of utilizing regular toilet facilities. 
 
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 chair. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that you are physically incapable of utilizing regular toilet facilities. There is 
no documentation that you are confined to a single room or confined to one level of the home environment 
without toilet facilities, or that you are confined to a home without toilet facilities. 
 
  
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 chair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a commode chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve left knee surgery for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the literature does not show any long-term improvements with this type of surgery due 
to presence of osteoarthritis. 
 
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 there is too much knee arthritis for arthroscopy surgery to be effective. It is not medically needed. 
 
  
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 left knee surgery for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need more care than what home health can give 
you. The Plan denied your request. The Plan says based on Medicare guidelines, the requested SNF services do 
not meet the requirements for approval. 
 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 that you do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 
skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on 
September 24, 2021. 
 
You asked the Plan to pay for pneumatic compression devices. You say that the requested items were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded 
as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for pneumatic compression devices (E0675, E0673) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (99072) provided on September 21, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services is always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of B under the Physician 
Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for 
other services. No separate payment can be made for code 99072. 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 services (99072) provided on September 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a visit with an endodontist. 
 
You asked the Plan to pre-approve a visit with an endodontist. You say that you cannot eat and you are in pain.  
You stated that you do not want to take more antibiotics because it could cause problems. The Plan denied your 
request. The Plan says services with an endodontist are not 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. The Plan contract specifically 
says that dental services are only covered if performed by a participating general dentist.  An endodontist is not 
a general dentist. 
 
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 pre-approve a 
visit with an endodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on November 5, 
2021. 
 
You asked the Plan to pay for a shoulder-arm orthosis. You say that the item at issue was a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment for DMEPOS have not been 
met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the information in 
the patients medical record adequately supports the medical necessity for the item.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The available medical records do not discuss the item at issue. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on November 5, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retroperitoneal ultrasound (76770) provided on October 
10, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that this is not a bundled charge. The Plan denied your 
request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists 
between 93976 and 76770. This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate modifier was not billed with this PTP code edit. This service was 
not billed as required by Medicare coding regulations. 
 
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 76770 
is a column II code to column I code 93976. 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 the retroperitoneal ultrasound (76770) provided on October 10, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary and the best option for 
the patient. 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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is insufficient literature in the peer reviewed publications to assess safety, efficacy, long term 
outcomes or patient management associated with the use of the MyoPro Orthosis for upper extremity 
paralysis/paresis from conditions such as the patient's peripheral nerve injury, CRPS 2 or other 
neuromuscular/neurological disease or injury. The requested device is not the standard of care for the patient's 
condition. The requested orthosis is not reasonable and necessary for the diagnosis or treatment of illness or 
injury or to improve the functioning of a malformed body member. 
 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MyoPro Motion G device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2335 x2) provided on 
January 5, 2022. 
 
You asked the Plan to pay for the resin-based composites. You say that the Plan representative you spoke with 
told you that you had dental coverage for x-rays, fillings, dentures, and partials. You also say that you feel the 
Plan should be responsible for this bill. The Plan denied your request. The Plan says this service is not a 
covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to this date 
of service to verify the provider or your 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 the two 
resin-based composites (D2335 x2) provided on January 5, 2022.  
Your complaint about being misinformed by the Plan representative about your dental coverage is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the parenteral nutrition infusion pump, portable (B9004) provided on 
August 16, 2021. 
 
You asked the Plan to pay for the parenteral nutrition infusion pump. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim 
was not billed with the correct place of service code. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support why this place 
of service code billed is inappropriate. It is the burden of the Health Plan to substantiate their denial with 
evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we 
decided that the Plan has to pay for the parenteral nutrition infusion pump, portable (B9004) provided on 
August 16, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by a 
network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that it is not safe for the enrollee to be discharged 
home at this time. The enrollee needs physical therapy and occupational therapy to gain strength to be able to 
return home. The Plan denied your request. The Plan says authorization denied because the SNF care is not 
medically necessary and the enrollee's needs can be met at a lower level of care such as home with home 
health, in residential care, or home with close follow-up with their doctor. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and 
is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. He is medically stable and can receive further rehab services at a lower level of care. 
Although further rehabilitation services would be appropriate to improve function, as a practical matter, the 
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee 
does not have any parental medication, daily complex wound care or nutrition given via a feeding tube. He is 
medically stable without any acute exacerbation of chronic medical problems.  His physical function is at or 
near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled 
rehab services is not 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for and waive the copayment for a prostate specific antigen 
(PSA) screening test and emergency room visit provided on September 8, 2021 and November 9, 2021. 
 
You asked the Plan to pay for and waive the copayment for PSA test and emergency room visit. You say that 
the PSA test was done as part of your annual physical, and the quick-care facility is attached to the front of the hospital and should only be billed as a $35 copayment. The Plan denied your request. The Plan says the denial 
of payment for the PSA test is correct, because you previously had a PSA screening in October 2020 so 12 
months had not passed before this test was performed. The Plan also says that the copayment amount you are 
being charged is correct. 
 
The rules say that PSA screening tests are covered once every 12 months. 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 $90 copayment for each emergency 
room visit. The provider of service for the visit on November 9, 2021 is part of a hospital emergency 
department; therefore, the emergency care copayment applies to this claim. 
 
You previously had a covered PSA screening test on October 15, 2020; therefore, fewer than 12 months had 
passed before this PSA test was performed on September 8, 2021. Therefore, Medicare rules for coverage of 
screening PSA test have not been met. You have been asked to pay $90 copayment for emergency room visit. 
Emergency room visit 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 pay for 
and waive the copayment for a prostate specific antigen (PSA) screening test and emergency room visit 
provided on September 8, 2021 and November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the optometry visit provided on October 
27, 2021. 
 
You asked the Plan to waive the cost sharing for the optometry visit. You say that this was an annual eye exam 
and should not have the specialist copayment. The Plan denied your request. The Plan says this was a medical 
eye exam and was correctly assessed the $40 copayment. 
 
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 $40 
copayment for Medicare-covered exams to diagnose and treat eye conditions.  
 
 
 You have been asked to pay a $40 copayment for the optometry visit. The records submitted by the provider 
show that this visit was a follow-up to a July 2021 visit for a horseshoe retinal tear. Because of this, the 
optometry visit falls within the Medicare-covered exams to diagnose and treat eye conditions 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 sharing for the optometry visit provided on October 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 20, 2021, to 
August 17, 2021. 
 
You asked the Plan to pay for the home health services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the RAP claim was not received with 5 days of the start of care. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, the record indicates the RAP was not 
submitted within 5 days of the from the start of care date, July 20, 2021. Therefore, we decided that the Plan 
does not have to pay for the home health services provided from July 20, 2021, to August 17, 2021.