Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on July 07, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you do not feel liable. 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 $10 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $10 copayment for an office visit. This item/service 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 copayment for an office visit provided on July 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of benign lesion (D7411) provided on June 27, 
2023. 
 
You asked the Plan to pay for D7411. You say that you needed this done because you were in pain. The Plan 
denied your request. The Plan says the rendered dental service is not a covered benefit. 
 
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 pay for the 
excision of benign lesion (D7411) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 72 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation (HFCWO) 
system (E0483). 
 
You asked the Plan to pre-approve a HFCWO system. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that high frequency chest wall oscillation devices 
(HFCWO) (E0483) are covered for beneficiaries who meet specific criteria. 
 
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 HFCWO system. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has not attempted or 
documented trial of standard therapy with mucolytic's or standard chest physiotherapy (CPT). The enrollee 
bronchoscopy results were underwhelming for severe mucous production and inability for secretion 
management. Hence, a trial mucolytic's and CPT would be best initial standard, in addition to Speech therapy 
to prevent further aspiration risk. Therefore, the enrollee does not qualify for HFCWO at this time given data 
and documentation provided. 
 
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 HFCWO system have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a high frequency chest wall oscillation (HFCWO) system (E0483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on June 27, 2023. 
 
You asked the Plan to waive the copayment for an office visit. You say that you were a patient in the hospital at 
the time of service, and you should not be 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 $25 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $25 copayment for an office visit. This item/service 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 copayment for an office visit provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on October 21, 2022. 
 
You asked the Plan to pay for the wound care supplies. 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 the wound care supplies 
provided on October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system (PERS). 
 
You asked the Plan to pre-approve a PERS. You say that you would like the Plan to reconsider their denial. 
The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
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 personal emergency response system (PERS).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from April 20, 2023, through 
April 26, 2023. 
 
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 that they cannot approve this new hospital 
stay as a separate admission. The hospital should include all expenses for this admission with your last hospital 
stay. 
 
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically 
necessary, and if the readmission did not result from a premature discharge from the same hospital. 
 
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 pay for these services. Our reviewer says that the 
acute inpatient hospital care provided was medically necessary. Our physician reviewer found that the 
readmission was medically necessary. The first admission was related to pneumonia which stabilized and 
improved with treatment. The enrollee was stable for discharge. The second admission was due to an 
exacerbation of congestive heart failure (CHF). The review has determined that the readmission did not result 
from a premature discharge from the same hospital.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from April 20, 2023, through April 26, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical dressings (A6457, A6448, E1399, A6449). 
 
You asked the Plan to pre-approve the surgical dressings. You say that these items are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that dressings are only covered when there is a qualifying 
wound. 
 
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 surgical dressings. Our reviewer 
says that the dressings requested are not medically necessary. Our physician reviewer found the provided 
documentation did not reveal a qualifying wound or skin breakdown required to meet criteria for these 
supplies.   
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 surgical dressings have not been met. Therefore, we decided that the Plan 
does not have to pre-approve surgical dressings (A6457, A6448, E1399, A6449).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the irrigation procedure provided on July 
10, 2023. 
 
You asked the Plan to reduce the copayment for the irrigation procedure. You say that this was not a surgical 
procedure. 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 surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $75 copayment for the irrigation procedure. This item/service falls within the 
outpatient surgery, including services provided at hospital outpatient facilities 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 reduce the copayment for the irrigation procedure provided on July 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis (L1851). 
 
You asked the Plan to pre-approve knee orthosis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that knee orthoses are 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 knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the clinical documentation provided 
does not support the need for a knee orthosis. The physical examination does not demonstrate right sided knee 
instability and there is no indication of recent trauma or surgery of the right knee. The brace is being order for 
the enrollees knee pain and osteoarthritis, which is not indicated per the guideline policy. Therefore, the 
requested knee orthosis (L1851) is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthosis (L1851).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an arthroscopic left knee meniscectomy including 
chondroplasty (29881).  
 
  
 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the 
requested service. 
 
The Plan follows Medicare rules. Medicare rules say that arthroscopic debridement and lavage with or without 
debridement for patients presenting with severe osteoarthritis 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 this service. Our reviewer says that the 
enrollee does not meet criteria for coverage of the requested service. Our physician reviewer found that the 
enrollee was being treated for unilateral primary osteoarthritis, chondromalacia of the left knee, and a tear of 
medial meniscus of the right knee. He presented with bilateral knee pain. The left knee has moderate pain rated 
at 7/10 with activity and no pain at rest. There is popping crepitance, stiffness, and loss of motion acutely. The 
exam reveals left knee full range of motion. There is tenderness at the medial joint line. There is a mildly 
positive McMurrays test. The September 28, 2023 magnetic resonance imaging of the left knee has findings 
consistent with osteophytes with chondral thinning in the medial compartment and full-thickness chondral loss 
in the patellofemoral compartment. These findings are most consistent with bordering on a grade 3 (moderate) 
Kellgren and Lawrence grade.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an arthroscopic left knee meniscectomy including chondroplasty (29881).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 15, 
2023. 
 You asked the Plan to pay for procedure code 99284. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99284 is bundled into payment for code 
99285. 
 
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, we have confirmed that code 99284 
is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99284 billed for date of service July 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 29, 
2023.  
 
You asked the Plan to pay for procedure code 99497. You say that the claim is billed correctly and should be 
paid. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 
99291. 
 
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, we have confirmed that code 99497 is a column two code to column one code 99291 with a modifier indicator of 0. The column two code is 
therefore not payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 99497 billed for date of service March 29, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transurethral destruction of prostate tissue procedure 
(53854). 
 
You asked the Plan to pre-approve the procedure. You say that this procedure is medically necessary. The Plan 
denied your request. The Plan says coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that transurethral destruction of prostate tissue is 
contraindicated in enrollees that have known or suspected prostate cancer. 
 
We looked at the file and Medicare rules. The records show a diagnosis of prostate cancer. Based on this 
information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a transurethral destruction of prostate tissue procedure 
(53854).
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 clearly meets long term 
acute care criteria. The Plan denied your request. The Plan says the enrollee's continued care needs include, 
respiratory support and tube feeding. The Plan says the enrollee can receive this care in the current acute care 
setting until being ready to transfer to a lower level of care. 
 
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 enrollee is receiving appropriate care in current acute care setting as provided by 
the Plan. Documentation does not support that LTACH services are medically appropriate currently. The enrollee's records do not support the need to transfer from one acute hospital to another. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional routine transportation trips.  
 
You asked the Plan to pre-approve the transportation services. The Plan denied your request. The Plan says the 
enrollee has used the allowed benefits. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a maximum of 36 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and related services provided on June 28, 2023. 
 
You asked the Plan to pay for a home visit, and related services. You say that this is supported in the records. 
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, and related 
services provided on June 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standard wheelchair for 13 months rental. 
 
You asked the Plan to pre-approve a standard wheelchair. You say that the item is necessary. The Plan denied 
your request. The Plan says the enrollee received a wheelchair in October 2019 for a 13-month rental. The 
equipment is less than 5 years old and there is no documentation indicating the existing equipment requires 
replacement. 
 
The Plan must follow Medicare rules. Medicare rules say that the MAC determines the reasonable useful 
lifetime for capped rental equipment but in no case can it be less than five years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a standard wheelchair for 13 months rental.