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

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on November 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 20550-59 (2 Units) remains not supported. 
 
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 20550 is "Injection(s); single tendon sheath, or ligament, 
aponeurosis (eg, plantar "fascia")." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the procedure report does not 
include documentation of an injection, single tendon sheath or ligament, aponeurosis. 
 
We looked at this coder's review, the file, and Medicare rules. 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 injection services provided to the enrollee on November 4, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve the use of an intrathecal pump for administration of Fentanyl. 
 
You asked the Plan to pre-approve Fentanyl via an intrathecal pump. You say that the requested service is a 
medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not 
been met because Fentanyl is not approved for use in an intrathecal pump. 
 
The Plan follows Medicare rules. The rules say that an implantable infusion pump is covered when used to 
administer opioid drugs intrathecally or epidurally for treatment of severe chronic intractable pain of malignant 
or nonmalignant origin in enrollees who have a life expectancy of at least 3 months when the criteria in the 
Medicare rules section have been met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Fentanyl via an intrathecal pump. Our 
reviewer says that the requested service is medically reasonable and necessary in this case. Our physician 
reviewer found that clinical practice guidelines as listed in standard textbooks support the use of Fentanyl in an 
intrathecal pump. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fentanyl via an intrathecal pump have been met. Therefore, we decided that the 
Plan has to pre-approve the use of an intrathecal pump for administration of Fentanyl.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the enterectomy, resection of small intestine (44120) and 
colostomy or skin level cecostomy (44320) provided September 17, 2021. 
 
You asked the Plan to pay for the surgical procedure. You say that the out of network provider was the only 
available assistant at the time of the procedure and rendered services specifically requested by the in network 
primary physician and in network facility. The Plan denied your request. The Plan says this provider is not 
certified/eligible to be paid for this procedure/service on this date of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the enterectomy, resection of small 
intestine (44120) and colostomy or skin level cecostomy (44320) provided September 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that in the case of a clinical laboratory test provided under 
an arrangement made by a hospital, CAH or SNF, payment is made to the hospital or SNF.  
 
We looked at the file and Medicare rules. The file shows that the laboratory services were provided by the 
hospital. Payment is included in the payment to the hospital. Therefore, we decided that the Plan does not have 
to pay for the laboratory services rendered on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network specialist office visit 
provided on January 5, 2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that this should be billed as in 
network The Plan denied your request. The Plan says the copayment applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $70 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). 
 
 You have been asked to pay $70 copayment for specialist office visit. Out of network specialist office visits fall 
within the Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that 
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for out of network specialist office visit provided on January 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to lower the copayment for an urgent care visit provided on March 13, 
2022. 
 
You asked the Plan to lower the copayment for the urgent care visit. You say that you were never notified that 
your copayment would be higher in 2022. The Plan denied your request. The Plan says an annual notice of 
change was sent to the enrollee in late September of 2021; therefore, the proper copayment was applied. 
 
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 
copayment for each Medicare-covered urgent care facility visit. This copayment is not waived if you are 
admitted as an inpatient to the hospital within 24 hours for the same condition.  
 
  You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the 
Urgently Needed 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 lower the copayment for an urgent 
care visit provided on March 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 20, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you went to the facility for a 
drive by coronavirus (COVID-19) test. You also said that when you went there, they did a few swabs, and you 
did not leave the car. You also said that your town insinuated it was free. The Plan denied your request. The 
Plan says based on a review of the additional information they received; it was determined that you did receive 
an urgent care visit rendered on January 20, 2022. The Plan also says you were 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 a $50 
copayment for each Medicare-covered urgent care facility visit.  
 
You have been asked to pay $27.23, which is less than the $50 copayment for an urgent care visit. An urgent 
care visit falls within the urgently needed 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 an urgent care visit provided on January 20, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthotic device (L1690) provided on February 22, 2022. 
 
You asked the Plan to pay for the orthotic device. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says documentation required for payment is 
missing. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Specifically, the documentation does not indicate that the ordering provider discussed the medical 
need for the requested equipment. 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 orthotic device (L1690) provided on February 
22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services, outpatient services, inpatient 
admission and physician's services provided from January 5, 2020, to August 5, 2020. 
 
You asked the Plan to pay for the emergency room services, outpatient services, inpatient admission and 
physician's services. You say that you have met your out-of-pocket maximum. The Plan denied your request. 
The Plan says you are responsible for the copayments 
 
 
 
 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 $90 
copayment for emergency care, a $300 copayment for outpatient hospital care, $420 per day, days 1-7; $0 per 
day, days 8-90; $0 copay for additional days for inpatient hospital care and a $30 copayment for physicians 
services.  
 
You have been asked to pay a $90 copayment for emergency care, a $300 copayment for outpatient hospital 
care, $420 per day, days 1-7; $0 per day, days 8-90; $0 copay for additional days for inpatient hospital care and 
a $30 copayment for physicians services. The emergency room services, outpatient services, inpatient 
admission and physician's services falls within the Emergency Care, Outpatient Hospital Services and 
Physician/Practitioner Services, Including Doctor's Office Visit 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 pay for emergency room services, outpatient services, inpatient admission and physician's services provided 
from January 5, 2020, to August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic leg with an electronic knee and other parts 
for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a request for microprocessor K3 knee is not medically reasonable or 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no documentation that the enrollee is a K3 level ambulator. The provided records 
documentation that she is functioning at a K2 level for ambulation and activity. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prosthetic leg with an electronic knee and other parts for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for a power wheelchair 
(E2311). 
 
You asked the Plan to pre-approve the accessory. You say that this is medically necessary. The Plan denied 
your request. The Plan says although there are two approved power options on this wheelchair (tilt, and 
elevating leg rests), there is not a medical need to control these power options through the joystick. 
 
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 accessory. Our reviewer says that 
the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that based on the medical records provided, there is no documentation that the electronic connection 
between the wheelchair controller and two or more power seating system motors at issue in this case meets 
Medicare criteria for medically reasonable and necessary. The documentation supports that you have 4-5/5 
right upper extremity strength with "good" right hand grip strength, thus indicating she has adequate upper 
extremity strength and function to operate the wheelchair's power options with their own switches. 
 
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 accessory have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection for a power wheelchair (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you would like the Plan to make the OON provider 
your primary physician. The Plan denied your request. The Plan says they overturned and paid two other claims 
with the OON provider and each time the enrollee was informed the provider is not in-network. Also, there was 
no referral from an in-network provider or an approved authorization to see the OON provider. 
 
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 an office visit provided on February 21, 2022, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5260) provided on April 2, 2021, from an 
out-of-network provider. 
 
You asked the Plan to pay for the hearing aids. You say that you did not know you had to get hearing aids 
through a specific network/provider. The Plan denied your request. The Plan says hearing aids are only covered 
when they are received from a participating (in-network) provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are received from a participating provider.  
 
We looked at the file and the Plan's rules. The hearing aids in this case were received from an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not 
been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5260) provided on April 
2, 2021, from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $87.51 coinsurance for an infusion on February 28, 2022. 
 
You asked the Plan to waive the $87.51 coinsurance for an infusion on February 28, 2022. You say that you 
should not be responsible for this cost share as it should be covered as a preventative service. The Plan denied 
your request. The Plan says enrollees are responsible for a 20% coinsurance for Part B drugs dispensed at an 
outpatient facility. 
 
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 Medicare Part B Prescription Drugs.  
 You have been asked to pay a $87.51 coinsurance for an infusion. An infusion falls within the Medicare Part B 
Prescription Drugs benefit category. The allowed amount was $437.50; $437.50x20%=87.51. You have also 
been asked to pay a $45 copayment for a specialist visit on February 28, 2022. The Plan contract states you are 
responsible to pay a $45 copayment for each Medicare-covered specialist visit. A specialist visit falls within the 
Physician/Practitioner Services, Including Doctors Office Visits benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the $87.51 coinsurance for an infusion on February 28, 2022, or the $45 copayment for a specialist 
visit on February 28, 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 you have had both legs amputated and you need the 
therapy. The Plan denied your request. The plan says you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not need intensive therapies consisting of at least three hours of 
therapy per day at least five days per week with multidisciplinary approach in an IRF.  The enrollee's rehabilitation needs can be safely provided in a lower intensity and alternate setting such as in a 
skilled nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh. 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the services 
are necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that positron emission tomography for oncologic 
conditions is covered for certain circumstances.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PET CT scan from the skull base to mid-thigh have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan from the skull base to mid-thigh.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex device. 
 
You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 a Vertiflex device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the vertiflex device is experimental. More research is needed to show safety and 
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 a Vertiflex device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Vertiflex device.