Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an impression and custom preparation; oral surgical 
splint. 
 
You asked the Plan to pre-approve an impression and custom preparation; oral surgical splint. You say that the 
enrollee would like to try this oral stint. The Plan denied your request. The Plan says the medical criteria for an 
oral stint has not been met. 
 
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. The Plan covers an impression 
and custom preparation; oral surgical splint when the services are medically necessary and reasonable.  
 
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 an impression and custom preparation; oral surgical splint have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an impression and custom preparation; oral 
surgical splint.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on December 21, 2022. 
 
You asked the Plan to pay for the acupuncture. You say that acupuncture has helped with the radiating pain 
across your chest. The Plan denied your request. The Plan says acupuncture services are only covered for 
chronic low back pain. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you do not have chronic low back pain. Therefore, 
we decided that the Plan does not have to pay for acupuncture provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided 
September 21, 2022. 
 
You asked the Plan to pay for a pneumatic compression device. You say that due to the type of surgery 
performed, combined with other risk factors as indicated, you feel that the medical necessity criteria outlined in 
the medical policy has been met/ The Plan denied your request. The Plan says a pneumatic compression device 
coded as E0676 is not covered. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for a pneumatic compression device (E0676) provided September 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the inpatient hospital stay provided from 
February 22, 2022, to February 27, 2022. 
 
You asked the Plan to provide reimbursement for the inpatient hospital stay. You say that you would like this 
cost reimbursed. The Plan denied your request. The Plan says that services received by the VA are not 
reimbursable by the Plan.  
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The Medicare rules state that the Plan does not have to reimburse 
services received from the VA. 
 
The record shows that you received inpatient hospital care by the VA, which is not reimbursable by the Plan. 
You have been asked to pay for the inpatient hospital stay. This item/service falls within the inpatient hospital 
care benefit category. Therefore, we decided that the Plan does not have to provide reimbursement for the 
inpatient hospital stay provided from February 22, 2022, to February 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 28, 2022. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not expect this 
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 physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $50 copayment for the specialist 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 the specialist office visit provided on November 28, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is 
medically necessary.  The Plan denied your request. The Plan says the requested Intracept procedure is not 
medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer 
says that the requested Intracept procedure is not medically necessary.  Our physician reviewer found the 
record shows that the enrollee has had a lumbar burst fracture. The cause of back pain is not clear. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 enrollee meets full IRF criteria. The Plan denied 
your request. The Plan says that the services do not meet the requirements for approval. 
 
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does 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. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 18, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
January 2, 2023. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you should not be held 
financially responsible for this visit. 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 $100 
copayment for Emergency Care/In-Network/Emergency Services.  
 
You have been asked to pay a $100 copayment for an emergency room visit. This item/service falls within the 
Emergency Care/In-Network/Emergency 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 January 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued physical therapy (PT) services. 
 
You asked the Plan to pre-approve the therapy services. You say that you would like to continue therapy in 
order to avoid surgery. The Plan denied your request. The Plan says the requested services are not reasonable 
or necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific 
and effective therapy for your condition beyond what was approved 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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued physical therapy (PT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoes.  
 
You asked the Plan to pre-approve foot orthotics. You say that you need these shoes for knee pain. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic shoes.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
December 29, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service December 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a personal emergency response system (S5161). 
 
You asked the Plan to pre-approve a personal emergency response system. The Plan denied your request. The 
Plan says this item is not covered by Medicare. You may wish to submit this request under the enrollee's 
Medicaid 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 personal emergency response system (S5161).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on October 14, 2021. 
 
You asked the Plan to pay for psychotherapy services. You say that the assessment should be covered. The 
Plan denied your request. The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on  
October 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve orthopedic shoe.  
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs orthopedic shoes for chronic 
pain. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve 
orthopedic shoe.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on August 23, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that your organization does not 
have a contract with the dialysis facility for payment of these lab services. The Plan denied your request. The 
Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on August 
23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided by a naturopath provider on 
December 8, 2022. 
 
You asked the Plan to pay for the office visit provided by a naturopath provider. You say that code 99214 is a 
standard code for an office visit, not an alternative therapy. The Plan denied your request. The Plan says your 
Plan does not cover alternative therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.  
 
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have 
to pay for an office visit provided by a naturopath provider on December 8, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs (A9270) provided on January 1, 
2023. 
 
You asked the Plan to pay for the medication. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the medication is not covered as a medical 
benefit under the Plan. 
  
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs provided here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
(A9270) provided on January 1, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on December 21, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that the services should be covered. 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 psychotherapy provided 
on December 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an in-network inpatient stay, and 
ambulance ride provided from August 7, 2022, to November 25, 2022. 
 
 
You asked the Plan to waive the copayments for an in-network inpatient stay and ambulance ride. You say that 
this is too much money for these services and should be waived. 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 $295 
copayment per day, for days 1-7 for inpatient hospital services, and a $285 copayment for ambulance services. 
 You were inpatient for 3 days, resulting in a $885 copayment. You also had an ambulance ride resulting in a 
$285 ($885 + $285 = $1,170). 
 
You have been asked to pay a $1,170 for an in-network inpatient stay and ambulance ride. This item/service 
falls within the inpatient hospital services, and ambulance 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 copayments for an in-network inpatient stay, and ambulance ride provided from August 7, 2022, 
to November 25, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the stress test and the regadenoson injection 
provided on February 8, 2023. 
 
You asked the Plan to waive the cost share for the stress test and the injection. You say that that you were told 
that you would not have 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 $50 
copayment for diagnostic procedures and tests. Your contract with the Plan also clearly says that you must pay 
20% coinsurance for drugs covered under Medicare Part B. 
 
You have been asked to pay a $50 copayment for the stress test. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. 
 
You have also been asked to pay up to 20% coinsurance for the injection. You have been asked to pay a total of 
$43, which is less than 20% of the allowed amount for the injection. This item/service falls within the Medicare 
Part B prescription 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 cost share for the stress test 
and the regadenoson injection provided on February 8, 2023.