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

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on June 27, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that you are disputing the share cost. 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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay $100 copayment for ultrasound. This item/service falls 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 June 27, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found he MyoPro is not known to be 
effective, based on scientific evidence, professional standards and expert opinion, in improving health 
outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. The services are therefore not 
reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits (97530, 
97116). 
 
You asked the Plan to pre-approve 6 additional PT visits. You say that the enrollee has hemiplegia and 
hemiparesis following cerebral infarction affecting left non-dominant side. The Plan denied your request. The 
Plan says 6 additional PT visits are not medically necessary. You should be able to transition to a home 
education program with the total approved visits. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 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 6 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found that the documentation does not support the need for 
additional 6 physical therapy visits. Additional visits are not medically necessary or reasonable based on the 
review of documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 6 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six (6) additional physical therapy (PT) visits (97530, 97116).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical supplies provided on May 27, 2022. 
 
You asked the Plan to pay for the billed services. You say that the charges are appropriate for the level of 
services provided. The Plan denied your request. The Plan says no separate payment is made. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that CPT code A4649 is a bundled code. Payment for the services is bundled into payment for other 
services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical supplies provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass cap (D6740) for teeth numbers 6 and 8 and 
a fixed prosthodontic (D6245) for tooth number 7. 
 
You asked the Plan to pre-approve a white glass cap (D6740) for teeth numbers 6 and 8 and a fixed 
prosthodontic (D6245) for tooth number 7. You say that due to the completed fracture and apical infection 
present, you recommend the extraction of tooth number 7, and the fixed bridge placement of teeth numbers 6 to 
8. You also say that a removable, partial denture would not be as stable as a traditional fixed bridge. The Plan 
denied your request. The Plan says this is not a medical necessity. 
 
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 a white glass 
cap (D6740) for teeth numbers 6 and 8 and a fixed prosthodontic (D6245) for tooth number 7 when the services 
are medically necessary and reasonable.  
 
 
  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 white glass cap (D6740) for teeth 
numbers 6 and 8 and a fixed prosthodontic (D6245) for tooth number 7. Our reviewer says that the service is 
not medically necessary. Our physician reviewer found there has been no documentation supplied that indicates 
there is a physical or neurological disorder that precludes placement of a removable appliance for this member, 
therefore, Plan criteria has not been met. Our physician reviewer also found that reporting that the member has 
a strong gag reflex is not sufficient to meet the Plan criteria. 
 
We looked at this physician's review, the file, and Medicare rules. The rules say that the Plan covers a white 
glass cap (D6740) for teeth numbers 6 and 8 and a fixed prosthodontic (D6245) for tooth number 7 when the 
services are medically necessary and reasonable. Based on this information, we decided that the Plan's rules for 
coverage of a white glass cap (D6740) for teeth numbers 6 and 8 and a fixed prosthodontic (D6245) for tooth 
number 7 have not been met. Therefore, we decided that the Plan does not have to pre-approve a white glass 
cap (D6740) for teeth numbers 6 and 8 and a fixed prosthodontic (D6245) for tooth number 7.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the monthly gym membership purchased for April 1, 
2022, to May 31, 2022. 
 
You asked the Plan to pay in full for the gym membership. You say that you would like to be reimbursed for 
the quarter. You also say that you were not aware this benefit would run out. The Plan denied your request. The 
Plan says your annual out-of-network maximum has been reached. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only up to $150 annually. 
 
The Plans rules for coverage of gym benefits have not been met because your $150 allowance for health and 
wellness education programs has already been exhausted. Therefore, we decided that the Plan does not have to 
pay in full for the monthly gym membership purchased for April 1, 2022, to May 31, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 20, 2021, through 
May 25, 2021. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says the RAP was 
not submitted within 5 calendar days. 
 
The Plan must follow Medicare rules. Medicare rules say that 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 home health services have not been met. Specifically, the RAP was not submitted within 5 
calendar days. Therefore, we decided that the Plan does not have to pay for home health services provided from 
April 20, 2021, through May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee is being treated for 
vertebrogenic low back pain. There is pain with flexion and extension at the waist. Lumbar facet loading is 
positive. There is tenderness to palpation of the bilateral sascroiliac joints. There are multiple plausible 
pathologic sources of significant pain generation. The documentation does not support actual formal surgical 
ablation of pre-designated basivertebral nerves as being medically necessary and/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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided on July 05, 
2022, to July 09, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that since you had to share the 
room with another patient you shouldnt have to pay the full amount. 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 $325 
copayment for Inpatient Hospital Care. 
 
You have been asked to pay a $325 copayment for inpatient hospital stay. This item/service 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. You have been asked to pay a total of $1,300 ($325 x 4 days) for your inpatient hospital 
stay. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital stay 
provided on July 05, 2022, to July 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), biological materials 
(D4265), guided tissue regeneration (D4266), and a bone replacement graft (D7953) for tooth #29 provided on 
June 23, 2022, and July 1, 2022. 
  You asked the Plan to pay for the dental services. You say that it was necessary to have your tooth removed 
and you would like a reversal of the denied claim. The Plan denied your request. The Plan says your benefit for 
the oral evaluation has already been exhausted. The denial of payment for the biological materials, guided 
tissue regeneration, and a bone replacement graft is correct, because the dental services are not covered by the 
Plan. 
 
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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on the date of service of April 7, 2022. Also, 
the biological materials, guided tissue regeneration, and a bone replacement graft are not a covered benefit 
under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation (D0140), biological materials (D4265), guided tissue regeneration (D4266), and a bone replacement 
graft (D7953) for tooth #29 provided on June 23, 2022, and July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing 
provided on March 1, 2021. 
 
You asked the Plan to pay for the cardiac risk assessment genetic screening testing. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
The Plan follows Medicare rules. Cardiovascular risk assessment panels are only covered for certain 
indications. 
 
While cardiovascular risk assessment panels are covered for certain indications, the file does not support that 
the enrollee met criteria for these services. The testing rendered is not a covered benefit. Therefore, we decided 
that the Plan does not have to pay for the cardiac risk assessment genetic screening testing provided on March 
1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on May 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the items are medically necessary. The Plan denied 
your request. The Plan says you do not use insulin with at least three daily injections or require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, and you have not had an in-person visit 
with your treating physician to assesses adherence to your CGM regimen and diabetes treatment plan. 
 
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 indicates that the enrollee does not you do not 
use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the 
blood glucose testing results, and you have not had an in-person visit with your treating physician to assesses 
adherence to your CGM regimen and diabetes treatment plan. Based on this information, we decided that 
Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment (DME) provided on May 15, 
2022. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says a valid proof of delivery 
was not provided. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. 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 the durable medical equipment (DME) provided on May 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care services (99291) billed for date of service July 5, 
2021. 
 
You asked the Plan to pay for critical care services. You say that you have provided records to support the 
services at issue. The Plan denied your request. The Plan says the available records do not support the services 
billed. 
 
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, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of 
the critically ill or critically injured patient; first 30-74 minutes." 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, the available records do not 
address the span of time over which the services at issue were provided. Based on this information, we decided 
that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan 
does not have to pay for critical care services (99291) billed for date of service July 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 25, 2022, to 
April 6, 2022. 
 
You asked the Plan to pay for the billed services. You say that the notice of admission was denied. The Plan 
denied your request. The Plan says a notice of admission was not received. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The information provided does not include a valid notice of admission for 
the services at issue. Based on this information, we decided that Medicare rules for coverage have not been 
met. Therefore, we decided that the Plan does not have to pay for the home health services provided from 
March 25, 2022, to April 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression socks. 
 
You asked the Plan to pre-approve compression socks. You say that you have been using these sicks for ten 
years and your current pair have holes in them. The Plan denied your request. The Plan says the requested 
items are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression socks 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 socks.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342 and 88360 billed for date of 
service February 25, 2022. 
 
You asked the Plan to pay for procedure codes 88341, 88342 and 88360. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that payment is not made under the physician fee schedule for Technical Component (TC) services 
furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital 
inpatient and outpatient settings. In addition, TC services furnished by independent laboratories to hospital 
patients are not payable by the MAC. 
 
We find that procedure codes 88341, 88342 and 88360 are physician pathology services which have both 
professional components (PC) and technical components. These services were not billed with modifier 26 to 
indicate that only the professional component payment is requested. This means that payment is requested for 
both the PC and TC of these services. However, these services were provided to an enrollee who was in an 
inpatient hospital setting at the time the sample was collected, which means that the TC component is bundled 
into the facility payment. The TC portion of these services are not separately payable, and therefore these 
services are not supported as billed. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 88341, 88342 and 88360 have not been met. Therefore, we decided that the Plan does not have 
to pay for procedure codes 88341, 88342 and 88360 billed for date of service February 25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment received by the 
member was medically necessary. The Plan denied your request. The Plan says the provider is not a contract 
provider with the Plan. The Plan also says that prior authorization was not 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 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 subsequent nursing facility care provided on June 
15, 2022, by an out-of-network (OON) provider.