Persius/hicric huggingface dataset:
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 at high risk for complications and is 
progressing in therapy. The Plan denied your request. The Plan says the enrollee can safely receive the services 
you need in other settings, for example: a skilled nursing facility, home with home health and home physical 
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 the enrollee was admitted to the hospital on 3/16/2022 with new onset seizures, with 
left hemiparesis and slurred speech. Imaging shows only evidence of prior strokes, no new infarcts. As of 
3/22/2022, the enrollee required minimal assistance for bed mobility, contact guard assist for transfers, and was 
able to ambulate up to 60 feet with minimal assistance and a rolling walker. 
 
The enrollee is medically stable does not need rehabilitation physician supervision 3 times per week (at a 
minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No 
acute rehab nursing needs identified or documented in the record. While the enrollee may benefit from physical 
and occupational therapy, at the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy in an IRF. The enrollee's rehab can be safely provided at a lower intensity. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for to waive the copayment for a specialist office visit provided 
on June 10, by an out-of-network (OON) provider and the surgery provided on July 6, 2021, by an out-of-
network (OON). 
 
You asked the Plan to pay for the surgery and a specialist office visit. You say that you were unaware that you 
needed a referral from your primary care physician. The Plan denied your request. The Plan says there was one 
approved authorization for the specialist office visit on June 10, 2021, with the out-of-network provider. There 
was no approved authorization for the visit on July 6, 2021, with the out-of-network provider therefore the 
claim was denied. Also, the service rendered was not urgent or emergent. 
 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 $20 
copayment for a Specialist's Office visit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
You have been asked to pay a $20 copayment for the specialist office visit. The specialist office visit falls 
within the Physician/Practitioner services, including doctor's 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 the specialist office visit provided on June 10, 2021. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgery provided on July 6, 2021, by an out-
of-network (OON).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by out-of-network providers on 
November 3, 2021, to November 15, 2021. 
 
You asked the Plan to pay for dental services. You say that you believe that you should be reimbursed for this. 
The Plan denied your request. The Plan says the claim has been processed correctly. 
 
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.  We looked at the file and Medicare rules. D9945 is not a covered benefit. Medicare rules say that Network 
dentists have agreed to provide services at a negotiated rate. If you see a network dentist, you cannot be 
billed more than that rate for covered services. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for 
dental services provided by out-of-network providers on November 3, 2021, to November 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 28, 2021, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the referring physician should be 
responsible for the authorization. The Plan denied your request. The Plan says the rendering and referring 
providers are both out-of-network providers and there was no approved authorization. Also, the service 
rendered was not urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 28, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (70450) provided on September 5, 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 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 the services (70450) provided on September 5, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to waive the deductible for lab services. We decided that the Plan has to reduce 
the charge to the correct copayment amount for surgery.  
 
You asked the Plan to waive the deductible for lab services and surgery. You say that you were charged for 
out-of-network costs. The Plan says that these were in-network outpatient hospital surgical services, so the 
deductible amount charged is correct. 
 
We decided that the Plan has to waive the deductible for in-network lab services.  
 
This service was provided by a specialist, so the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category that was used by the Plan to charge a 
deductible is not appropriate.  
 
Outpatient lab services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. Your contract with the Plan clearly says that you must pay a $0 copayment for in-network 
outpatient lab services.  
 
Therefore, we decided that the Plan has to waive the deductible for lab services. 
 
We also decided that the Plan has to reduce the charge to the correct copayment amount for in-network 
surgery. 
 
This service was provided by a specialist, so the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers benefit category that was used by the Plan to charge a 
deductible is not appropriate. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Specialist provided surgery falls in the Physician/Practitioner 
Services, Including Doctors Office Visits benefit category. Your contract with the Plan clearly says that you 
must pay a $35 copayment for physician specialist services. Covered services include: Medically-necessary 
medical care or surgery services furnished in a physicians office. Therefore, we decided that the Plan has to 
reduce the charge to the correct copayment amount of $35 for surgery. 
 
The plan must waive the deductible for the lab services (code 88173) and reduce the charge to the correct $35 
copayment for the surgery (code 10005). 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Colonoscopy on October 22, 2021. 
 
You asked the Plan to waive the copayment for a Colonoscopy. You say that there shouldn't be a charge for this 
colonoscopy. The Plan denied your request. The Plan says the copayment you are being charged 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 a $225 
copayment for a Colonoscopy.  
 
You have been asked to pay a $225 copayment for Colonoscopy. A Colonoscopy 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 waive the copayment for a Colonoscopy on 
October 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory work provided on August 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for laboratory work provided on August 11, 2021, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Superion interspinous spacer device. 
 
You asked the Plan to pay for the Superion interspinous spacer device. 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 pay for the Superion interspinous spacer device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that FDA indications include implantation of the Superion device at one or two 
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no 
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA 
indicated levels of moderate spinal stenosis (including the planned level of implantation L4-5.)  There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity 
of this request as an exception to guidelines. 
 
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 Superion interspinous spacer device have not been met. Therefore, we 
decided that the Plan does not have to pay for the Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CGM and supplies (CPT code(s): K0554 and 
K0553) 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 received did not state that you are treated with 
multiple shots in a day and the documentation does not show that check your blood for more than three (3) 
times. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve the CGM and supplies (CPT code(s): K0554 
and K0553)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702). 
 
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro is appropriate for the enrollee 
including for the duration and frequency. The Plan denied your request. The Plan says this item is considered 
experimental and investigational. 
 
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 the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-
approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
December 7, 2021, to December 11, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel you were 
under observation status and not inpatient for this visit. The Plan denied your request. The Plan says you have 
been charged 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 $200 per 
day for days 1-6 and $0 per day for days 7-90 for each inpatient admission.  
 
The file shows that you were in the hospital from December 7, 2021, to December 11, 2021, but there is no 
copayment for the discharge date. Therefore, you have been asked to pay $200 per day for the first 4 days of inpatient hospital services. The inpatient hospital services fall 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 services provided from 
December 7, 2021, to December 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2331) provided by a contracted 
provider on November 22, 2021. 
 
You asked the Plan to pay for a resin-based composite. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says the benefit limit for D2331 has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers two resin-
based composites per calendar year. 
 
We looked at the file and Medicare rules. Evidence was provided to show that D2331 was provided on January 
5, 2021. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have already been met. Therefore, we decided that the Plan does not have to pay for a resin-based composite 
(D2331) provided by a contracted provider on November 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are appealing the denial of the 
stockings. You called the Plan and was initially told that they were covered. The Plan denied your request. The 
Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Dexcom CGM and supplies (CPT code(s): K0554 
and K0553) 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the Medicare rules have 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 show that the enrollee's insulin 
treatment regimen requires frequent adjustment based on their blood glucose meter. Based on this information, 
we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the Dexcom CGM and supplies (CPT code(s): K0554 and K0553)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from July 27, 2021, to 
August 17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says maintenance therapy is 
not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The submitted documentation does not contain medical records from 
the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been 
met. 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 chiropractic services provided from July 27, 
2021, to August 17, 2021.