Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the physical therapy services. We decided that the 
Plan does not have to waive the copayment for the physical therapy services.  
 
You asked the Plan to waive the copayment for the physical therapy services provided by an in-network 
provider on September 20, 2022. You say that you believe you were billed in error for this service. The Plan 
says that this cost sharing was charged correctly. 
 
 
 We decided that the Plan has to reduce the copayment for the physical therapy services.  
 
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 says that you must pay a $40 
copayment for each in-network Medicare-covered physical therapy visit. The Plan says you must pay a $45 
copayment for the physical therapy services. Based on the Plan contract, however, you cannot be asked to pay 
more than $40 for in-network physical therapy services. Therefore, we decided that the Plan has to reduce the 
copayment for the physical therapy services.  
 
We also decided that the Plan does not have to waive the copayment for the physical therapy services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each in-network Medicare-covered physical therapy visit. 
 
The physical therapy services fall within the in-network outpatient rehabilitation services benefit category. This 
means that you are responsible for a $40 copayment 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 physical therapy services provided by an in-network provider on 
September 20, 2022. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrical stimulator (E0730), provided on August 14, 
2022. 
 
You asked the Plan to pay for the electrical stimulator. You say that the item should be covered. The Plan 
denied your request. The Plan says the enrollee did not receive this item. 
 
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 for the supplies provided in this case. The delivery and 
packing slips do not have a date that matched the date of service. 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 electrical stimulator (E0730), provided on August 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on October 12, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that the records attached support the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a nursing facility visit 
provided on October 12, 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. The Plan denied your request. The Plan says the clinical 
information does not meet the guidelines for IRF, the records indicate the needs may be safely met at a skilled 
nursing facility. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for guided tissue regeneration (D4266), 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone replacement graft 
for ridge preservation - per site(D7953). We also decided the Plan does not have to pay for the panoramic 
radiographic image (D0330) provided on October 31, 2022. 
 
You asked the Plan to waive the coinsurance for codes D4266, D7210, D7953 and pay for code D0330. You 
say that this was an emergency situation as you broke your tooth and could not wait another five years. The 
Plan denied your request. The Plan says the coinsurance was appropriately applied to codes D4266, D7210, 
D7953 provided. The Plan also says your $1,000 benefit period program maximum for the year after all other 
claims processed leave you with a $824.80 responsibility. 
 
 
SERVICE 
DENTIST 
CHARGE 
ALLOWED 
AMOUNT 
INELIGIBLE 
AMOUNT 
% 
COVERED 
 
COINSURANCE 
ENROLLEE 
PAYS 
PLAN 
PAYS 
D0330 $210 $0 $210 0% $0 $76 $0 
D7210 $455 $195 $260 50% $97.50 $97.50 $97.50 
D4266 $745 $421 $324 50% $210.50 $210.50 $210.50 
D7953 $805 $805 $0 50% $402.50 $440.80 $364.20 
TOTAL $2,215 $1,421 $794  $710.50 $824.80 $672.20 
 
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 50% 
coinsurance for Class 2 Basic dental services. 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. 
 
You have been asked to pay a 50% coinsurance for codes D4266, D7210, D7953. This service falls within the 
dental 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 coinsurance for guided tissue regeneration 
(D4266), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), bone 
replacement graft for ridge preservation - per site (D7953) provided on October 31, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for panoramic radiographic image (D0330) was exhausted on date of service January 22, 
2020. There fore we decided the Plan does not have to pay for code D3330.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to stay a few more days to build more 
strength in your legs. The Plan denied your request. The Plan says the continued SNF stay is not medically 
indicated. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
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 cannot be adequately cared 
for in the current facility and is stable for LTACH transfer. The Plan denied your request. The Plan says the 
LTACH services requested do not meet requirements for approval. 
 
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 record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied, and the requested service cannot be recommended. 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 22, 2022. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 22, 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 the services are necessary for close medical 
management of your current medical needs. The Plan denied your request. The Plan says the services you need 
can be provided in another setting such as in a skilled nursing facility, home with home health services, or 
home with outpatient 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 you continue to have a need for skilled therapy with ongoing safety concerns and a 
potential for functional improvement however, the documentation doesnt support that you would meet criteria 
for admission to an acute inpatient rehabilitation facility. You can receive further services at a lower level of 
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 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are requesting reconsideration for the denial of 
an IRF admission. The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF 
services. 
 
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 the enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total shoulder arthroplasty with customized shoulder 
implant (CPT code 23472). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of a customized shoulder implant in the 
setting of rotator cuff tear arthropathy have not been demonstrated in the peer-reviewed literature. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation is not evident regarding significant findings of the shoulder that support 
the need of a custom shoulder implant over standard implants. Moreover, there is limited published, large-
scale, long-term peer-reviewed literature that shows this request to be an effective (regarding ultimate 
outcomes of pain relief and/or function) and/or safe treatment for the noted pathology. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the request for is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the total shoulder arthroplasty with customized shoulder implant (CPT code 23472).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
September 20, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copaymet. 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 $75 
copayment for emergency care. 
 
You have been asked to pay a $75 copayment for emergency room services. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room services 
provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous ablation of the basivertebral nerve 
(64628, 64629). 
 
You asked the Plan to pre-approve the Intracept Procedure. You say that the Intracept Procedure is medically 
necessary and supported by strong science. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare. 
 
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 Intracept Procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental and investigational. There is more research 
needed due to insufficient evidence of efficacy. 
 
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 Intracept Procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an intraosseous ablation of the basivertebral nerve (64628, 64629).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the automatic external defibrillator (K0606), provided on 
July 4, 2021. 
 
You asked the Plan to pay for the automatic external defibrillator. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the automatic external defibrillator was not filed until November 7, 2022. 
This means that more than one calendar year from the date of service had passed before a claim was filed. 
Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator (K0606), 
provided on July 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan with computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the requested testing. You say that the imaging may provide information 
specific to estrogen receptor positive (ER+) lesions. The Plan denied your request. The Plan says 
radiopharmaceutical Fluoroestradiol is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
The file shows that a PET scan using Cerianna (Fluoroestradiol F18) was 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 testing. Our physician reviewer found that the 
enrollee has breast cancer with known ER+ axillary disease. Cerianna is indicated for use with positron 
emission tomography (PET) imaging for the detection of estrogen receptor (ER) positive lesions as an adjunct 
to biopsy in patients with recurrent or metastatic breast cancer. Limitations of Use Tissue biopsy should be 
used to confirm recurrence of breast cancer and to verify ER status by pathology. Cerianna is not useful for 
imaging other receptors, such as human epidermal growth factor receptor 2 (HER2) and the progesterone 
receptor (PR). As limitations state, a tissue biopsy should be used to confirm metastatic disease. An initial 
biopsy of the bone was negative and was not hypermetabolic on the conventional PET CT. Therefore, the 
request is not medically necessary.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan with 
computed tomography (CT) scan.