Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an advanced foot and ankle feature. 
 
You asked the Plan to pre-approve an advanced foot and ankle feature. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says that the requested device is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that advanced foot and ankle features are covered for 
certain indications. 
 
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 prosthetic leg with an advanced foot 
and ankle feature. Our reviewer says that the documentation does support that requested items are medically 
reasonable and necessary. Our physician reviewer found the enrollee has a left transtibial amputation. The 
enrollee's existing prosthesis is reportedly ill-fitting (25 sock ply) and the existing foot is worn out and off 
warranty. The documentation shows that the enrollee is a K3 ambulator. The enrollee is therefore entitled to an 
L5981 foot, as this is the standard of care based simply on the K-level per the LCD, as well as its addition 
codes L5968 and L5986 per Medicare criteria. The enrollee is an unlimited community ambulator who is also 
working full time. The enrollees context is adequately described in the Certified Prosthetist/Orthotist note with corroboration by the prescribing Medical Doctor, and there are no current, physically debilitating comorbidities 
described that should limit the enrollees actual potential to meet the K3 criteria. The Plan's objection to billing 
for L5968 and L5986 because it supposedly amounts to a duplicate ankle is not supported in the LCD or Policy 
Article; for instance there is no warning against using these codes together as unbundling. Therefore, the 
enrollee meets criteria for the requested items. 
 
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 prosthetic leg with an advanced foot and ankle feature have been met. 
Therefore, we decided that the Plan has to pre-approve an advanced foot and ankle feature.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for chiropractic care on January 19, 2023, to 
January 31, 2023. 
 
You asked the Plan to waive the cost share for chiropractic care. You say that you were not advised that 
chiropractic services were only covered by means of manual manipulation. 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 $15 
copayment for each Medicare-covered chiropractic service. Covered services include we cover only manual 
manipulation of the spine to correct subluxation. The provider billed in the amount of $469. Therefore, results 
in the total cost sharing amount of $469. 
 You have been asked to pay a $469 cost share for chiropractic care. This item/service falls within the 
chiropractic 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 cost share for chiropractic care on 
January 19, 2023, to January 31, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for colonoscopy provided on January 17, 2023. 
 
You asked the Plan to waive the copayment for colonoscopy. You say that you say you dont want to pay for 
the bill. 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 $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $250 copayment for colonoscopy. 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 colonoscopy provided on January 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the detailed documentation is not evident regarding a significant past 
and/or current medical history that would place you at increased risk for peri-surgical complications requiring 
an inpatient stay. No compelling rationale is presented, or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the record does not show that at the time of 
inpatient admission, the admitting physician reasonable expected that your necessary hospital care would span 
two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care for the surgery.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a kyphoplasty procedure. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is in excruciating pain. The 
Plan denied your request. The Plan says the procedure is contraindicated. 
 
The Plan follows Medicare rules. Medicare rules say that a kyphoplasty procedure is only covered under 
certain medical indications.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee is being treated for pain in the thoracic spine. Detailed documentation, 
including the magnetic resonance imaging (MRI) of the lumbar spine, shows additional plausible causes of 
pain. Per the MRI, osseous degenerative change in the thoracic spine including disc bulges and facet 
hypertrophy resulting in stenosis from T10-11 through T12-L1, small protrusions cannot be excluded but there 
is no definite spinal cord or nerve root impingement. No compelling rationale is presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
kyphoplasty at T11, in this case, is not indicated for the enrollees 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a kyphoplasty procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266), the extractions 
(D7210), and bone replacement graft (D7953) for tooth #18, #30, and #31 provided by an out-of-network 
provider on June 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary, 
and you would like the Plan to re-consider the denied services. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. Also, the guided tissue regeneration and bone replacement graft 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 Plan's coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the extractions are not covered under this benefit when 
received from an out-of-network provider. The guided tissue regeneration and bone replacement graft are not 
covered under the Plan's dental benefit. Therefore, we decided that the Plan does not have to pay for the guided 
tissue regeneration (D4266), the extractions (D7210), and bone replacement graft (D7953) for tooth #18, #30, 
and #31 provided by an out-of-network provider on June 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 88360 and 88381 billed for date of service 
March 10, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360 and 88381. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says these codes are included in the 
facility payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s) 88360 and 88381. 
This means there is both a professional and technical component for the CPT code(s). In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT code(s) 88360 and 
88381. Based on this information, we decided that Medicare rules for coverage of procedure codes 88360 and 
88381 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code(s) 
88360 and 88381 billed for date of service March 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network colonoscopy provided on 
January 05, 2023. 
 
You asked the Plan to waive the copayment for an in-network colonoscopy. You say that you had two previous 
tests done, and were advised to have a full colonoscopy. You were not aware there would be a 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 $150 
copayment for outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. 
 
You have been asked to pay a $150 copayment for an in-network colonoscopy. This item/service falls within the outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility 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 in-network colonoscopy provided on 
January 05, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the clinic visit provided on May 26, 2022. 
 
You asked the Plan to waive the copayment for the clinic visit. You say that there should not 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 a $75 
copayment for outpatient hospital services. 
 
You have been asked to pay a $75 copayment for the clinic visit. This item/service falls within the outpatient 
hospital 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 the clinic visit 
provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endoskeletal knee-shin system, single axis, fluid 
swing and stance phase control (L5828). 
 
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the item is not medically necessary. 
 
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 item. Our physician reviewer found 
an L5828 endoskeletal knee-shin system, single axis, fluid swing and stance phase control exceeds the patient's 
medical needs and does not meet Medicare medically necessary criteria per the Social Security Act, Section 
1862 (a)1(A) and the 42 Code of Federal Regulations (CFR) Section 411.15(k), as Medicare does not pay for 
any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or 
to improve the functioning of a malformed body member. The requested K3 exceeds the enrollee's functional 
needs as the documentation does not support that this enrollee is a K3 level ambulator. 
 
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 item have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the endoskeletal knee-shin system, single axis, fluid swing and stance phase control (L5828).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that you would like to appeal this service because 
the doctor ordered you get the colonoscopy as a study. The Plan denied your request. The Plan says your doctor 
did not submit the necessary medical information for this service to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a colonoscopy have been met. Medical 
records were not provided for this case. The record shows that the Plan made multiple attempts to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy (45378).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery 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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the bone marrow aspirate remains experimental. More research is needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee scooter. 
 
You asked the Plan to pre-approve a knee scooter. You say that you need this for after surgery. You say that 
you cannot be weight-bearing for 10 days post-surgery. You also say that you will need this to get around your 
home so that you do not fall. The Plan denied your request. The Plan says a knee scooter is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a knee scooter.
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 LTACH would be the best option for this 
enrollee to receive the best care and prevent readmission, given the enrollee's current respiratory care needs and 
medical complexity. The Plan denied your request. The Plan says the enrollee can safely receive their care in 
another setting, such as a skilled nursing facility. 
 
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 they 
are not currently receiving but that would be available at the LTACH facility. The elements of the coverage 
rules are not satisfied. 
 
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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to 
September 27, 2022.  
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from March 12, 2022, to 
September 27, 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 medically necessary to increase 
strength and endurance while managing the enrollee's medical needs to ensure a safe return home. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting. 
 
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 require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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.