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

 
We decided that the Plan has to pre-approve an oral sleep device. 
 
You asked the Plan to pre-approve an oral sleep device. You say that the item is medically necessary. The Plan 
denied your request. The Plan says that this item is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an oral sleep device. Our reviewer says 
that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has sleep apnea and is intolerant to continuous positive airway pressure (CPAP). This is a 
recognized and often effective therapy for mild to moderate obstructive sleep apnea in patients who are 
intolerant of CPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oral sleep device have been met. Therefore, we decided that the Plan has to 
pre-approve an oral sleep device.  
 
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: 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 prior to inpatient admission you were living 
independently at home. Because of Covid your muscles weakened and for you to be able to continue to live 
independently you need inpatient rehabilitation to strengthen muscles. The Plan denied your request. The Plan 
says the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitative care. The Plan says that the services needed 
may be provided safely in a lower level of care. 
 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 your 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: 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 was previously at the 
LTACH and had to be transferred back to the hospital. Currently cannot get the care needed.  The Plan denied 
your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable 
for transfer. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bevacizumab injection provided on 
March 15, 2023. 
 
You asked the Plan to waive the coinsurance for a bevacizumab injection. You say that you do not agree that 
you should be responsible for that coinsurance since other insurances pay for it. 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 Medicare-covered Part B drugs.  
 
 
  You have been asked to pay $14.15 in coinsurance, which is less than the 20% coinsurance for a bevacizumab 
injection. This item/service falls within the Medicare-covered Part B drugs 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 a bevacizumab injection provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330), a bone replacement graft for 
ridge preservation (D7953), and extractions (D7210), provided on March 8, 2023, to March 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have a $2,000 allowance for dental benefits. 
The Plan denied your request. The Plan says these services have been processed correctly. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for D0330 was exhausted on date of service July 27, 2022. A 20% coinsurance has been 
applied to D7210. D7953 is not a covered benefit. Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330), a bone replacement graft for ridge preservation (D7953), and extractions 
(D7210), provided on March 8, 2023, to March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D dental surface scan  direct (D0801). 
 
You asked the Plan to pre-approve 3D dental surface scan  direct. You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 3D 
dental surface scan  direct (D0801).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023, to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.  
 
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 S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023, to April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assessment/care planning provided on April 12, 2023, by an 
out-of-network (OON) provider.  
 
 You asked the Plan to pay for assessment/care planning. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be 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 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 assessment/care planning provided on April 12, 
2023, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the VivAer procedure (30801, 30117, 30469). 
 
You asked the Plan to pre-approve the VivAer procedure. You say that this is medically necessary. The Plan 
denied your request. The Plan says the criteria for reasonable and necessary are not met as this device has not 
been shown to be safe and effective for treatment of the enrollee's condition. 
 
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 VivAer procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the enrollee has nasal obstruction and chronic 
sinusitis. There is insufficient literature to support the safety and efficacy of the requested service for the 
enrollee's specific conditions.  
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 VivAer procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the VivAer procedure (30801, 30117, 30469).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bariatric surgery. 
 
You asked the Plan to pre-approve bariatric surgery. You say that bariatric surgery is medically necessary. The 
Plan denied your request. The Plan says the requested bariatric surgery does not meet the Medicare coverage 
criteria.  
 
The Plan follows Medicare rules. Medicare rules say that bariatric surgery is covered when the criteria listed in 
the Medicare rules section of this decision 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 bariatric surgery. Our reviewer says 
that the requested bariatric surgery is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollees current BMI 49.4 kg/m2. The enrollee has undergone gastric bypass 
procedure in 2006. An upper gastrointestinal series (UGI) revealed hiatal hernia. Medical necessity of gastric 
bypass revision is not determined at this time. There is no anatomic complication of the prior gastric bypass 
that requires revision of the gastric pouch and jejunum. Revision gastric bypass has not been shown to result in 
any durable long term weight loss outcomes with normal Roux-en-Y gastric bypass (RYGB) anatomy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve bariatric surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 30, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided on 
March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92012) and 
diagnostic imaging of retina (92134) provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination (92012) and diagnostic imaging of 
retina (92134). You say that this should have been your 30 day check up. You also say you had to reschedule 
your appointment due to COVID-19 and a blizzard, so it was five months after the 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 $30 
copayment for a medical eye examination. 
 
You have been asked to pay a $30 copayment for a medical eye examination (92012) and diagnostic imaging of retina (92134). This item/service falls within the a medical eye examination 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 medical eye examination (92012) and diagnostic imaging of retina 
(92134) provided on February 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 96365, 96366, 96521, and J1817 for date of service 
March 23, 2023. 
 
You asked the Plan to pay for codes 96365, 96366, 96521, and J1817. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services billed are 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. 
 
We find that codes 96365, 96366, 96521, and J1817 are not supported in the medical record. Specifically, the 
documentation shows that Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or 
continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea 
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration was performed. 
This means codes 96365 and 96366 are not supported and there is a more appropriate code to be billed for these services. The medical records submitted include an order to perform refilling and maintenance of portable 
pump; however, the records indicate that Outpatient Intravenous Insulin Treatment (OIVIT) was performed and 
doesnt include a procedure report for pump maintenance refill. This means the validity and accuracy of the 
billed service is not met. The documentation shows that Nova R was administered via intravenous treatment. 
There is a more appropriate code to be billed for this service; therefore, code J1817 cannot be verified. 
 
Based on this information, we decided that Medicare rules for coverage of codes 96365, 96366, 96521, and 
J1817 have not been met. Therefore, we decided that the Plan does not have to pay for codes 96365, 96366, 
96521, and J1817 for date of service March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the insertion of a bladder catheter provided 
on April 21, 2023. 
 
You asked the Plan to waive the copayment for the insertion of a bladder catheter. You say that you do not 
agree with 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 $50 
copayment for each in and out-of-network Medicare-covered specialist office or telehealth visit. 
 
You have been asked to pay a $50 copayment for the insertion of a bladder catheter. This item/service falls 
within the each in and out-of-network Medicare-covered specialist office or telehealth 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 waive the copayment for the insertion of a bladder catheter provided on April 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scaling  full mouth, after oral evaluation (D4346). 
 
You asked the Plan to pre-approve scaling  full mouth, after oral evaluation. You say that this should be 
covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
scaling  full mouth, after oral evaluation (D4346).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care (11043/99348) provided on April 12, 2023. 
 
You asked the Plan to pay for home health care (11043/99348). 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 home health care 
(11043/99348) provided on April 12, 2023.
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 admission is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not safe for the enrollee to leave the hospital at this 
time and are receiving the care needed in the current hospital. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan. 
 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 pre-approve the office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the office visit. You say that it is too difficult to drive to a different 
provider. The Plan denied your request. The Plan says you must receive your care from a network 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the item/service at issue in this appeal. We found no exception that would require 
the Plan to pre-approve this item/service. Therefore, we decided that the Plan does not have to pre-approve the 
office visit to be provided by an out-of-network (OON) provider.