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

 
We decided that the Plan does not have to pay for the cystourethroscopy services coded 52281 provided on 
February 11, 2022. 
 
You asked the Plan to pay for the cystourethroscopy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately 
payable. 
 
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 52281 
is a column II code to column I code 52440 with a modifier indicator of 0. The column II code is therefore not 
payable. 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 cystourethroscopy services coded 52281 provided on February 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ure-Na nutritional supplement. 
 
You asked the Plan to pre-approve Ure-Na. You say that you would like this supplement covered for medical 
necessity. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for orally administered 
nutritional supplementation. 
 
The items you asked the Plan to pre-approve are orally administered. Although these may be appropriate, 
neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to 
pre-approve Ure-Na nutritional supplement.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service March 11, 
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 March 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and based on your current level of function, 
you do not require intensive daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you have no complex medical issues complicating your rehabilitation needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the patient has been well controlled and established 
on this medication. You also say that hindering this will jeopardize diabetic control. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.  
 
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH 
admission criteria under CMS guidelines. You say that the enrollee is stable for transfer, and she requires 
prolonged and intensive skilled services that are not available at a lower level of care. The Plan denied your 
request. The Plan says authorization denied because the LTACH is not medically necessary, and the enrollee's 
needs can be met at a lower level of care such as a long-term care facility. 
 
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 enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can be safely completed at the current facility until appropriate for 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. 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 long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120). 
 
You asked the Plan to pre-approve additional transportation. You say that you need more trips to you have 
transportation to future appointments. You also say that you do not have the money to pay out of pocket for 
transportation. The Plan denied your request. The Plan says you have already used twenty-three (23) trips. The 
Plan also says that you have one (1) trip remaining, and this request exceeds your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation (A0120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is a good candidate for a two-week 
inpatient admission to improve strength and functional status. The enrollee has a nursing need and medical 
management for her conditions. The Plan denied your request. The Plan says authorization denied because the 
IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a 
skilled nursing facility (SNF). 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have complex rehabilitation needs or medical co-morbidities 
requiring acute inpatient care. The enrollee does not have muscle spasms, autonomic instability, or significant 
medical instability. The enrollee's condition does not meet Medicare criteria for admission to an inpatient 
rehabilitation facility 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on April 28, 2021. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be covered since you were 
not aware of the copayment. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $25 
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.  
 
You have been asked to pay $25 copayment for ultrasound. Ultrasounds fall within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for ultrasound provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260 x 2), bone replacement grafts 
(D4263 x 2), guided tissue regeneration (D4266 x 2), and surgical removal of implant (D6100). 
 
You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied 
your request. The Plan says the requested services are not listed as covered. The Plan also says that any service 
not listed is not covered. 
 
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, the requested dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260 x 2), bone replacement grafts (D4263 x 2), guided tissue regeneration (D4266 x 2), 
and surgical removal of implant (D6100).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 5, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that you would like for this to 
be paid. You also say that you no longer want to receive mailings about your mother. The Plan denied your 
request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible for 
coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is 
revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering 
services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth visit provided on January 27, 
2022. 
 
You asked the Plan to waive the copayment for telehealth visit. You say that you never had this service. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $40 
copayment per specialist visit.  
 
You have been asked to pay $40 copayment for telehealth visit. Telehealth visits fall within the 
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 telehealth visit provided on January 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options and accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with multiple power options and 
accessories. 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 items. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who meet specific criteria. 
 
Review of the file shows that you can drive a car, feed yourself, and live independently. The documentation 
also shows that you were negative for edema, arthralgias, myalgias, paresthesias, or weakness. You do not 
have any current pressure injuries. Your documented bilateral elbow, wrist, and hand strength are three out of 
five. This means you do not have a medical need for the requested F3 Base Corpus power wheelchair with the 
tilt and power recline power options. Therefore, we decided that the Plan does not have to pre-approve a group 
three power wheelchair with multiple power options and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve viscosupplementation therapy with Synvisc-One. 
 You asked the Plan to pre-approve viscosupplementation therapy. You say that you believe this is medically 
necessary. The Plan denied your request. The Plan says the records do not support that the enrollee meets 
coverage criteria for Synvisc-One. 
 
The Plan follows Medicare rules. Medicare rules state that viscosupplementation therapy with drugs such as 
Synvisc-One may be covered if certain criteria are met. 
 
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 viscosupplementation therapy. Our 
reviewer says that the enrollee does not meet Medicare criteria for the requested use of Synvisc-One. Our 
physician reviewer found the record does not include plain imaging results confirming the diagnosis of 
osteoarthritis of the knee. The record does not indicate failure of 3 months of simple analgesics or conservative 
therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of viscosupplementation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve viscosupplementation therapy with Synvisc-One.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from November 25, 
2021, to November 26, 2021. 
 
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated.  
The enrollee ended Medicare Hospice benefits on November 15, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital 
care provided from November 25, 2021, to November 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
December 30, 2021, to January 10, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that its not your fault you had 
problems from a procedure and had to be admitted into the hospital. You believe this should be covered. The 
Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $260 
copayment each day for days 1 through 7 for Medicare covered hospital care.  
 
 
 
 You have been asked to pay $1,820 copayment ($260 x 7 days) for inpatient hospital stay. 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 inpatient hospital stay provided from December 30, 2021, to January 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye exam provided on March 1, 2022. 
 
You asked the Plan to waive the copayment for eye exam. You say that this was a routine eye exam so it should 
be covered. The Plan denied your request. Since the enrollee was already diagnosed with cataracts this was not 
considered a routine exam. The Plan says the copayment applied is correct. 
 
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 $35 
copayment for each Medicare-covered eye exam.  
 
You have been asked to pay $35 copayment for eye exam. Eye exams fall within the Vision 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 eye exam provided on March 1, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that shower bars are medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CT scan provided on September 2, 2021. 
 
You asked the Plan to waive the coinsurance for CT scan. You say that this service never happened so it should 
be covered. The Plan denied your request. The Plan says the coinsurance applied is correct. 
 
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 20% 
coinsurance for Medicare- covered radiological diagnostic services, not including x-rays, when performed in a 
hospital, outpatient hospital, or a free- standing facility imaging or diagnostic center.  
 
 
 
 
 You have been asked to pay $32.85 which is 20% of the allowed amount for CT scan. The allowed amount is 
$164.23 ($164.23 x 20%= $32.85). CT scans fall within the Outpatient Diagnostic Tests and Therapeutic 
Services and Supplies benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for CT scan 
provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses provided on March 24, 2022. 
 
You asked the Plan to pay for polycarbonate lenses. You say that you expect full payment of CPT code V2784 
for polycarbonate lenses. The Plan denied your request. The Plan says the frames and bifocal lenses were paid. 
The Plan also says lens enhancements are not covered. 
  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
We looked at the file and the Plan's rules. Specifically, lens enhancements are not covered. Based on this 
information, we decided that the Plan's rules for coverage of polycarbonate lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for polycarbonate lenses provided on March 24, 2022.