Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a prosthetic device provided from April 
27, 2022, to May 4, 2022. 
 
You asked the Plan to waive the coinsurance for a prosthetic device. You say that you are not disputing your 
portion of the cost share, but you would like to be reimbursed for the portion that you paid out-of-pocket. 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 20% 
coinsurance for an out-of-network prosthetics provider.  
 
You have been asked to pay a coinsurance of $373.53, which is 20% of the allowed amount for a prosthetic 
device ($1,867.60 allowed x 20% = $373.53). This item/service falls within the 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 coinsurance for a prosthetic device 
provided from April 27, 2022, to May 4, 2022.   
Your complaint about not being reimbursed by the provider for a payment 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from April 27, 2021, 
to May 22, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like this claim to be 
reprocessed for payment. The Plan denied your request. The Plan says the initial request for anticipated 
payment (RAP) claim was not received within 5 calendar days from the start of care. The Plan also says that 
the non-contracted provider submitted the RAP claim on July 19, 2021. 
 
The Plan must follow Medicare rules. Medicare rules say that all HHAs must submit a 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. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days from the start of care date. Therefore, we decided that the Plan does not have to 
pay for the home health care services provided from April 27, 2021, to May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020) and single vision lenses (V2100). 
 
You asked the Plan to pre-approve the frames and lenses. You say that the glasses you received in February did 
not correct the issue in your right eye. The Plan denied your request. The Plan says you are only eligible for 
one optical benefit per year. The Plan also says that you already received this service this year. 
 
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. The Plan covers up to 1 pair of eyeglass lenses and 1 pair of eyeglass frames every two calendar 
years. 
 
We looked at the file and the Plan's rules. The record shows that the Plan issued payment for a pair of frames 
(V2020) and bifocal lens (V2203) provided on February 15, 2022, and your eyewear benefit has been 
exhausted. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses 
have not been met. Therefore, we decided that the Plan does not have to pre-approve frames (V2020) and 
single vision lenses (V2100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept intraosseous ablation of the basivertebral 
nerve. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried conservative 
treatment without relief. The Plan denied your request. The Plan says this service is considered experimental. 
 
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 requested services. Our physician 
reviewer found that the enrollee is being treated for vertebrogenic low back pain. In this case, there are multiple 
plausible pathologic sources of significant pain generation. The back pain radiating down the left leg, along 
with the diminished and painful spinal motion with flexion and extension, and intact neurologic exam are all 
non-specific to any pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or 
evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of 
the enrollees chronic persistent pain. The documentation does not support actual formal surgical ablation of 
pre-designated basivertebral nerves as being medically necessary or reasonable 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept intraosseous ablation of the basivertebral nerve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says coverage 
criteria 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 indicate that you require frequent self-
adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided 
that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a continuous glucose monitor.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for hospital observation services provided 
May 2, 2022, to May 3, 2022. 
 
You asked the Plan to reduce the copayment for hospital observation services. You say that you should only be 
responsible to pay the cost share for an emergency room visit. 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 $200 
copayment for each outpatient hospital observation service.  
 
 
 
 
 
 
 You have been asked to pay $200 for hospital observation services. This item/service falls within the outpatient 
hospital observation 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 hospital 
observation services provided May 2, 2022, to May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve a portable ventilator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode with 
Auto-EPAP (AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a portable ventilator. Our reviewer says 
that a portable ventilator is not medically reasonable and necessary. The enrollee has chronic respiratory failure 
from chronic obstructive pulmonary disease. The provided primary source documentation does not contain 
sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be 
treated with a BiPAP machine with average volume-assured pressure support (AVAPS) capability. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve multiple vascular procedures. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee does not have claudication or pain at rest in the feet. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The file shows that the revascularization of the iliac, popliteal, and tibial/peroneal arteries were requested. 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 requested services. Our physician 
reviewer found that the enrollee can walk without difficulty. There is no documentation of ischemic rest pain in 
his feet. An 8 out of 10 pain in the calves while driving and bilateral hip pain during ejaculation are not typical 
symptoms for peripheral artery disease. There is no evidence of wound or tissue loss.  It is unclear why femoral 
and popliteal pulses were not evaluated. Dorsalis pedis pulses are documented as "2", which normally indicates 
a palpable pulse. The physical exam ankle brachial index (ABI) report is nonsensical. No formal ABI study is 
provided. The duplex scan does not demonstrate severe occlusive disease other than isolated posterior tibial 
occlusion on the right with the remaining tibial arteries patent. The primary care provider was planning 
assessment of his lumbar spine. It is unclear if this has been completed. As there is no evidence of claudication 
or limb threat, medical necessity of the requested treatment is not supported. 
 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve multiple vascular procedures.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 88321 provided on January 31, 
2022. 
 
You asked the Plan to pay for the laboratory services as billed. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been 
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 88321 
is a column II code to column I code 88323 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 laboratory services coded 88321 provided on January 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are requesting LTACH services for 
the enrollee. The Plan denied your request. The Plan says the services needed could be provided in another 
setting, such as an acute rehabilitation facility, skilled nursing facility, outpatient setting or home care. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inversion table. 
 
You asked the Plan to pre-approve an inversion table. You say that it is a less invasive treatment for your pain. 
The Plan denied your request. The Plan says the item does not meet the definition of durable medical 
equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an inversion table.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee is receiving appropriate 
inpatient care at the current hospital and can remain there until ready for discharge to a lower level of care. 
 
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 the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection of triamcinolone acetonide (a 
Medicare Part B prescription drug) provided on April 26, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drug. You say that you did not have to pay this amount 
in the past. 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 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $560.32, resulting in a 
coinsurance amount of $112.06. 
 
You have been asked to pay 20% coinsurance for Part B drug. This item/service falls within the Medicare Part 
B Prescription Drugs 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 an 
injection of triamcinolone acetonide (a Medicare Part B prescription drug) provided on April 26, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service June 7, 2022. 
 
You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976.  
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 76705 
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 procedure code 76705 billed for date of service June 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for chemotherapy administration and 
bevacizumab injections provided on April 13, 2022. 
 
You asked the Plan to reduce the cost share for chemotherapy administration and bevacizumab injections. You 
say that your previous cost share responsibility was only $78.52. 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 20% 
coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug.  
 
 
 
 You have been asked to pay $656.62, which is 20% of the allowed amount for the chemotherapy administration 
and bevacizumab injections. The allowed amount is $3,283.08 (20% x $3,283.08 = $656.62). Chemotherapy 
administration and bevacizumab injections fall within the Medicare Part B Prescription Drugs benefit category. 
Chemotherapy administration and bevacizumab injections fall within the Medicare Part B Prescription Drugs 
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 cost share for chemotherapy administration and 
bevacizumab injections provided on April 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on June 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that the services were rendered to the enrollee in 
good faith and medically necessary. The Plan denied your request. The Plan says prior authorization was not 
obtained before the services were rendered. 
 
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 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. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on June 13, 2022, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an open implantation of a neurostimulator. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is an ideal candidate for 
sacral nerve stimulation. The Plan denied your request. The Plan says the enrollee does not need an open 
approach. 
 
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 requested services. Our physician 
reviewer found that the enrollee has urinary frequency, urgency, and urge incontinence. Treatment with 
medications was unsuccessful. The Axionics trial showed greater than 75% symptomatic improvement. The 
records do not show that the requested open procedure is medically necessary over a less invasive approach. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an open implantation of a neurostimulator.