Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you could greatly improve from therapy to strengthen your legs and be more independent. The Plan denied your request. The Plan says the services you need can be provided safely in other settings.

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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a different 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
March 26, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not feel that you 
should be responsible for the copayment. 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 $90 
copayment for in and out-of-network emergency room services. 
 
You have been asked to pay a $90 copayment for an emergency room visit. This item/service falls within the in 
and out-of-network emergency room 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 emergency room visit provided on March 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on November 28, 2022. 
 
You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration for 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 outpatient visit provided 
on November 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for eye surgery provided on April 27, 2023. 
 
You asked the Plan to waive the copayment for eye surgery. You say that you want to appeal the amount being 
charged. 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 $375 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $375 copayment for eye surgery. This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 eye surgery provided on April 27, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the services requested are medically necessary. The 
Plan denied your request. The Plan says the skilled nursing facility (SNF) services requested do not meet the 
requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ferric carboxymaltose injections provided 
on May 02, 2023, to May 15, 2023. 
 
You asked the Plan to waive the coinsurance for ferric carboxymaltose injections. You say that you were not 
aware that there would be a cost share. 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 in and out-of-network Part B drugs purchased at a pharmacy, administered by a pharmacist, or 
administered by a health care professional.  
You have been asked to pay 20% coinsurance for ferric carboxymaltose injections. This item/service falls 
within the in and out-of-network Part B drugs purchased at a pharmacy, administered by a pharmacist, or 
administered by a health care professional 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. The total you owe is $496.70 ($2483.46 allowed amount x 20% = $496.70 
rounded up). Therefore, we decided that the Plan does not have to waive the coinsurance for ferric 
carboxymaltose injections provided on May 02, 2023, to May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on February 17, 
2023. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that this should not be considered 
surgery. 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 $150 
copayment for outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $150 copayment for the arthrocentesis. This item/service falls within the 
outpatient surgery provided at an outpatient hospital 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. According to Medicare an arthrocentesis (CPT code 20610) is 
considered outpatient surgery. Therefore, we decided that the Plan does not have to waive the copayment for 
the arthrocentesis provided on February 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140), neuromuscular reeducation 
(97112), therapeutic exercises (97110), unlisted modality (97039), and the electrical stimulation (G0283) 
provided from August 10, 2022, through September 21, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the enrollee has exhausted the allowable 
benefit for the services provided in this case.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan provides supplemental coverage for 20 
routine chiropractic and acupuncture visits per year.   
 
 
 
The Plan contract states that 20 routine chiropractic and acupuncture visits are covered per year. The record 
shows that 20 chiropractic visits have been provided and paid for by the Plan for the 2022 calendar year for this 
enrollee. Therefore, the enrollee has exhausted the allowable benefit for the services provided in this case. 
Therefore, we decided that the Plan does not have to pay for the manual therapy (97140), neuromuscular 
reeducation (97112), therapeutic exercises (97110), unlisted modality (97039), and the electrical stimulation 
(G0283) provided from August 10, 2022, through September 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is bed ridden and unable to stand or 
pivot. The enrollee is unable to care for herself in a home setting. The Plan denied your request. The Plan says 
the Skilled Nursing Facility (SNF) services requested do not meet the requirements for approval. 
 
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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electronic connection between 2 or more systems 
(E2311) expandable controller (E2377) and expandable controller harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that please review and authorize this 
needed mobility device. The Plan denied your request. The Plan says the upgraded electronics cannot be 
covered as there is not a medical need to control the requested 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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head 
array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic 
devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an 
attendant control. The documentation does not support that it is medically necessary to control the requested 
power options through the joystick (drive interface). The enrollee's right upper extremity strength and 
functional ability as evidenced by being able to perform grooming should be sufficient to control any power 
options through their own switches. The documentation does not reveal that the E2377 expandable controller, 
E2313 expandable controller harness and E2311 electronic connection are medically necessary per Local 
Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve electronic connection between 2 or more systems (E2311) expandable controller 
(E2377) and expandable controller harness (E2313).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the dental service (D2750). We decided that the Plan does not 
have to pre-approve the dental service (D7210).  
 
You asked the Plan to pre-approve the dental services (D7210 and D2750). You say that the services requested 
are medically necessary.  The Plan says that the dental services D7210 and D2750 don't meet the criteria for 
approval. 
 
We decided that the Plan has to pre-approve the dental service (D2750).  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crown 
restorations 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 crown restoration (D2750) of tooth #21. 
Our reviewer says that you meet criteria for this service. Our physician reviewer found tooth #21 has 
significant coronal breakdown. A crown restoration is medically reasonable and necessary to provide adequate 
masticatory function and support. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of crown restoration D2750 have been met. Therefore, we decided that the Plan 
has to pre-approve the dental service (D2750).  
 
We also decided that the Plan does not have to pre-approve the dental service (D7210). 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers surgical 
extraction 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 surgical extraction (D7210) of tooth 
#13. Our reviewer says that you do not meet criteria for this procedure. Our physician reviewer found the 
documentation indicates that tooth #13 has less than 50% bone. It does not appear that bone removal would be 
necessary for tooth removal. Removal via elevation and forceps (D7140) seems adequate for removal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of surgical extraction D7210 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the dental service (D7210). 
 
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 pre-approve implantation of a hypoglossal nerve stimulation array 
(64582). 
 
You asked the Plan to pre-approve implantation of a hypoglossal nerve stimulation array. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hypoglossal nerve stimulation can be covered when 
specific criteria are 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 implantation of a hypoglossal nerve 
stimulation array. Our reviewer says that there is no documentation that the hypoglossal nerve stimulator at 
issue in this case meets all Medicare criteria for medically reasonable and necessary for the patient. Our 
physician reviewer found the provided records in this case do not document CPAP failure (defined as AHI 
[apnea hypopnea index] greater than 15 despite CPAP usage) or CPAP intolerance (defined as less than 4 hours 
per night, 5 nights per week or the CPAP has been returned) including shared decision making that the patient 
was intolerant of CPAP despite consultation with a sleep expert. Records document an AHI of 1.1 on CPAP 
and 92% compliance with CPAP at least 4 hours per night, average usage 6 hours 31 minutes per night. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of a hypoglossal nerve stimulation array have not been met. 
Therefore, we decided that the Plan does not have to pre-approve implantation of a hypoglossal nerve 
stimulation array (64582).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a duplex scan of extracranial arteries 
provided on March 21, 2023. 
 
You asked the Plan to waive the copayment for a duplex scan of extracranial arteries. You say that the doctor is 
not a level 2 provider. 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 $44 
copayment for in-network services received from all other specialists besides a Level 1 specialist physician. 
 
You have been asked to pay a $44 copayment for a duplex scan of extracranial arteries. This item/service falls 
within the in-network services received from all other specialists besides a Level 1 specialist physician benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for a duplex scan of extracranial arteries provided 
on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service August 9, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that the documents authenticate the billed codes. 
The Plan denied your request. The Plan says procedure code 99100 is considered bundled and not separately 
payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. 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 procedure code 
99100 billed for date of service August 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on March 14, 
2023. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you should not have a cost 
share for the supplies. 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 durable medical equipment (DME) and related supplies.  
 
  You have been asked to pay a total of $105.12 for diabetic supplies.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
March 14, 2023 A4231/Supplies $313.50 20% $62.70 
March 14, 2023 A4231/Supplies $62.70 20% $12.54 
March 14, 2023 A4232/Supplies $149.40 20% $29.88 
TOTAL:    $105.12 
 
These items fall within the durable medical equipment (DME) 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 diabetic supplies provided on March 14, 2023.