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

 
We decided that the Plan does not have to reduce the copayment for the endoscopy provided on December 21, 
2022. 
 
You asked the Plan to reduce the copayment for the endoscopy. You say that you were told you would only 
have a $180 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 $225 
copayment for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay a $225 copayment for the endoscopy. This item/service falls within the in-network 
outpatient surgery provided at an outpatient hospital benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The records show the surgery was provided at an outpatient 
hospital facility. Therefore, we decided that the Plan does not have to reduce the copayment for the endoscopy 
provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  first 15-minutes 
(D9222) and deep sedation/general anesthesia  each subsequent 15-minute increment (D9223). 
 
You asked the Plan to pre-approve dental services. You say that you do not agree with the denial of services. 
The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
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. Deep sedation/general 
anesthesia  first 15-minutes (D9222) and deep sedation/general anesthesia  each subsequent 15-minute 
increment (D9223) are not covered under the Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9222 and D9223 are 
not among those covered under this benefit.    Therefore, we decided that the Plan does not have to pre-approve 
deep sedation/general anesthesia  first 15-minutes (D9222) and deep sedation/general anesthesia  each 
subsequent 15-minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a resin-based composite (D2393) for tooth #2 and 
periodontal scaling and root planing (D4341) on all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that routine cleanings and x-rays are covered. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
the resin-based composite and periodontal scaling and root planing 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 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 a 
resin-based composite (D2393) for tooth #2 and periodontal scaling and root planing (D4341) on all 4 
quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee brace (L1843). 
 
You asked the Plan to pre-approve a knee brace. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace is covered if the beneficiary has had 
recent injury to or a surgical procedure on the knee(s), or has knee instability that is documented by joint laxity. 
 
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 knee brace. Our reviewer says that the 
item is not medically necessary. Our physician reviewer found the enrollee has no recent surgery nor injury nor 
instability. 
 
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 knee brace have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee brace (L1843).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says the criteria for 
approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI of the lumbar spine provided on 
January 21, 2023. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were told your coverage was 
accepted and you assumed it would be covered at no charge. 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 $350 
copayment for an MRI.  
 
 You have been asked to pay a $240.67, which is less than the standard $350 copayment. This item/service falls 
within the diagnostic radiology 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 
MRI of the lumbar spine provided on January 21, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after May 
26, 2023. 
 You asked the Plan to pre-approve continued SNF care. You say that the continued admission to a SNF is 
medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says 
that the requested SNF care is not considered medically reasonable and necessary based on Medicare 
guidelines.  Our physician reviewer found you do not have daily skilled nursing needs that require the 
specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled 
therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. 
You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility 
(SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care after May 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code G0127 for date of service January 12, 2023. 
 
You asked the Plan to pay for procedure code G0127. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the services are not payable as billed. 
 
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, the CPT Code Manual definition of code G0127 is trimming of dystrophic nails, any number. 
 
We find that CPT code G0127 is not supported in the medical record. Specifically, this service was not billed 
with the appropriate anatomical modifier. This code is not payable as billed. Based on this information, we 
decided that Medicare rules for coverage of procedure code G0127 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code G0127 for date of service January 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services received by 
the enrollee from September 8, 2022, to September 16, 2022. 
 
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the claim was processed correctly per the 
enrollee's benefits. 
 
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 35% 
coinsurance for inpatient mental health care received from an out-of-network provider. 
 
 You have been asked to pay 35% coinsurance for the inpatient hospital services. These services fall within the 
inpatient mental health care 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 the 
inpatient hospital services received by the enrollee from September 8, 2022, to September 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve avulsion of the lumbar median branch nerves and facet 
debridement services. 
 
You asked the Plan to pre-approve avulsion of the lumbar median branch nerves and facet debridement 
services. You say that the records provided support the need for the services in dispute.  The Plan denied your 
request. The Plan says Medicare guidelines do not recognize the requested services as commonly performed for 
facet mediated pain. The Plan says that there does not appear to be widespread acceptance of the procedure in 
the medical literature and consensus guidelines. The Plan says that adoption of the procedure appears to be 
limited to case reports and small case series.  
 
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 avulsion of the lumbar median branch 
nerves and facet debridement services. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case.  Our physician reviewer found the enrollee has chronic neck 
and lower back pain. Physical examination demonstrated tenderness at the lumbar spine and positive facet 
loading maneuvers. A magnetic resonance imaging scan of the lumbar spine from April 13th, 2021, showed 
bilateral facet arthrosis at multiple levels, as well as multilevel lateral recess and neural foraminal stenosis, and 
central stenosis at L1-2. The enrollee did not have good results from a prior lumbar radiofrequency ablation. 
Avulsion of the lumbar median branch nerves and facet debridement at L4-5 and L5-S1 would be considered 
experimental and investigational, as there is only small case series in the literature.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of avulsion of the lumbar median branch nerves and facet debridement services 
have not been met. Therefore, we decided that the Plan does not have to pre-approve avulsion of the lumbar 
median branch nerves and facet debridement services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration for the 
denial and have submitted medical records for review. The Plan denied your request. The Plan says the request 
is not medically necessary because the records show that the ordered settings for the noninvasive ventilator can 
be delivered by a bi-level PAP machine with AVAPS capability. The enrollee had PFTs, but we did not receive 
any results of testing of ABG while asleep or shortly after waking or see results of an overnight sleep oximetry. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD. The 
enrollee was recently hospitalized with acute exacerbation of COPD, requiring intubation. ABGs when acutely 
ill were consistent with acute on chronic hypercarbic respiratory failure. There is no ABG done while stable to 
document chronic CO2 retention. If that is present, the enrollee may benefit from BiPAP with AVAPS during 
sleep as an outpatient. Medicare does not cover a home ventilator when used at settings that can be provided 
with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided on January 26, 2021, to February 4, 2021, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this should be paid for. The Plan denied your request. The Plan says that that the DRG was updated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. Our Medical director looked at the case file and the reopen request. At issue is payment for inpatient hospital services at the DRG originally billed. In this case, you billed the inpatient services provided with principal diagnosis code, G92, defined as Toxic encephalopathy. Our Medical Director states that Toxic encephalopathy describes acute mental status alteration due to medications, illicit drugs, or toxic chemicals. The available clinical documentation supports the use of code G92 (Toxic encephalopathy), and DRG 091 (Other disorders of nervous system with major complication or comorbidity). Our Medical Director found that the enrollee's condition met Medicare criteria for the inpatient hospital services provided from January 26, 2021, to February 4, 2021, at the DRG originally billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital services provided on January 26, 2021, to February 4, 2021, at the Diagnosis Related Group (DRG) originally billed.
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the WATS3D testing (88112, 88361, 88312, 88305) 
provided on December 10, 2021.  
 
You asked the Plan to pay for  the WATS3D testing. You say that this testing is recommended in the standard 
of practice guideline of major medical studies. The Plan denied your request. The Plan says the clinical value 
and effectiveness of WATS3D testing for screening, diagnosis, or surveillance of cancerous or pre-cancerous 
esophageal lesions 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 pay for the WATS3D testing. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee's available record does not support the high likelihood of Barretts esophagus. 
The record also does not support that the enrollee has anything more than uncomplicated gastroesophageal 
reflux disease (GERD) as reflected in the ICD-10 diagnosis assigned by the provider. The available records do 
not support that the enrollee meets the spirit of American Society for Gastrointestinal Endoscopy (ASGE) 
guidance relative to medically necessary use of WATS-3D. 
 
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 WATS3D testing have not been met. Therefore, we decided that the Plan 
does not have to pay for  the WATS3D testing (88112, 88361, 88312, 88305) provided on December 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
You asked the Plan to pre-approve an electronic connection. You say that the item is medically necessary. The Plan denied your request. The Plan says that the right upper limb strength and function are adequate for you to be able to control the power options using their own switches which are included in the allowance of these power options. Maximus overturned the Plan's denial. The Plan requested a reopening and stated that we did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller, harness and electronic connection. Our Medical Director states that the clinical documentation supports that the enrollee has adequate right upper limb strength (4/5) and function to be able to control the power options using their own switches. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an electronic connection.
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 electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging (code 51798) and hospital outpatient clinic visit (G0463) provided to the enrollee on July 14, 2022.
You asked the Plan to waive the copayment for these services. You say that you would like the Plan to reconsider this claim. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each outpatient hospital visit.
The enrollee has been asked to pay a $124.82 copayment for these services. This item/service falls within the outpatient hospital visit benefit category. This means that the enrollee has been asked to pay less than the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging (code 51798) and hospital outpatient clinic visit (G0463) provided to the enrollee on July 14, 2022.