Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the orthotic device, outpatient office visit, 
and x-ray provided from March 1, 2023, to March 29, 2023. 
 
You asked the Plan to waive the coinsurance for the orthotic device, outpatient office visit, and x-ray. You say 
that you did not think you should trave for these services. 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 45% 
coinsurance for out-of-network durable medical equipment and related supplies. Your contract with the Plan 
also clearly says that you must pay 45% coinsurance for out-of-network specialist office visits. Your contract 
with the Plan also clearly says that you must pay 45% coinsurance for out-of-network x-rays.  
 
You have been asked to pay $37.72, which is 45% coinsurance of the allowed amount for the orthotic device 
($83.82 allowed amount x 45% coinsurance = $37.72). This item/service falls within the durable medical 
equipment and related supplies benefit category. You have been asked to pay $59.90, which is 45% 
coinsurance of the allowed amount for the specialist office visit ($133.12 allowed amount x 45% coinsurance = 
$59.90). This item/service falls within the physician/practitioner services benefit category. You have been 
asked to pay $3.75, which is 45% coinsurance of the allowed amount for the specialist office visit ($8.44 
allowed amount x 45% coinsurance = $3.75). This item/service falls within the outpatient diagnostic tests and 
therapeutic services benefit category. 
 
You have been asked to pay a total of $101.37 ($37.72 coinsurance + $59.90 coinsurance + $3.75 coinsurance 
= $101.37). 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 orthotic device, outpatient office visit, 
and x-ray provided from March 1, 2023, to March 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on February 22, 2023, through March 13, 2023. 
 
You asked the Plan to pay for the water circulating heat pad with pump. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on February 22, 2023, 
through March 13, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for Medicare Part B prescription drugs and an 
outpatient diagnostic test provided on December 20, 2022. 
 
You asked the Plan to waive the cost share for Medicare Part B prescription drugs and an outpatient diagnostic 
test. You say that you disagree with the 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 20% 
coinsurance for Medicare Part B prescription drugs and a $250 copayment for outpatient diagnostic 
tests/Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B prescription drugs and a $250 copayment 
for an outpatient diagnostic test. The total allowed amount for the prescription drugs is $245.38. You are being 
asked to pay $49.08 ($245.38 x 20% = $49.08). This item/service falls within the Medicare Part B prescription 
drugs and outpatient diagnostic tests/Medicare-covered diagnostic radiology services benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for Medicare Part B prescription drugs and an outpatient 
diagnostic test provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft (D7286), deep 
sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15 
minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and limited oral 
evaluation - problem focused (D0140) provided on March 27, 2023, and June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial and would like the 
plan to reconsider. The Plan denied your request. The Plan says you have been found as being excluded from 
the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.  
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue-soft 
(D7286), deep sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each 
subsequent 15 minute increment (D9223), therapeutic parenteral drug, single administration (D9610), and 
limited oral evaluation - problem focused (D0140) provided on March 27, 2023, and June 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized elliptical (E1399).

You asked the Plan to pre-approve exercise equipment. You say that you disagree with the denial. The Plan
denied your request. The Plan says the requested equipment 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 motorized elliptical (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found bone marrow aspirate is experimental 
in nature when used as a bone graft in spine surgery. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says an epidural 
steroid injection 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 injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that the LCD criteria 
requires that epidural steroid injections produce greater than 50% pain relief for three months, which was not 
achieved. Therefore, the request is not medically reasonable and 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a single axis, fluid swing and stance phase control (L5828), a 
stance flexion feature (L5845), a fluid stance extension dampening feature (L5848), and a microprocessor 
control feature (L5856). 
 
You asked the Plan to pre-approve the microprocessor knee. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says that the requested items exceed the 
enrollee's needs. 
 
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 the microprocessor knee. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found that not only does the medical record go above and beyond in satisfying Medicare 
rules by demonstrating the enrollee has K3 functional level potential and has specific needs for the requested 
components. In this case, lesser devices simply would not meet his functional needs and would amount to 
substandard 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 the microprocessor knee have been met. Therefore, we decided that the Plan has 
to pre-approve a single axis, fluid swing and stance phase control (L5828), a stance flexion feature (L5845), a 
fluid stance extension dampening feature (L5848), and a microprocessor control feature (L5856).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found that there are no large volume, long-
term/high-quality clinical studies that confirm the clinical benefits (ultimate outcomes of functional 
improvement and pain reduction) of computer-assisted surgery over standard surgical approaches in (reverse) total shoulder arthroplasty. No compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception to guidelines. Therefore, the requested computer-assisted 
surgical navigation for the approved reverse total shoulder arthroplasty is not medically reasonable or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computer-assisted surgical navigation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and the transitional care management services 
provided on April 8, 2023, to April 13, 2023, by an OON provider.  
 You asked the Plan to pay for an office visit and the transitional care management services. You say that you 
are requesting reconsideration of the denied claim. The Plan denied your request. The Plan says the service was 
not authorized. 
 
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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. The Plan contract says the enrollees POS benefit only applies to covered 
routine dental services. 
 
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 an office visit and the transitional care 
management services provided on April 8, 2023, to April 13, 2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress, identified 
with code E0277. 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you are a fall risk 
and are losing independence. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pressure-reducing air mattresses are only covered for 
certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a powered pressure-reducing air 
mattress. Our reviewer says that the documentation does not support that the requested item is medically 
reasonable or necessary. Our physician reviewer found the documentation shows that you are experiencing a 
progressive loss of strength due to Amyotrophic lateral sclerosis (ALS). You are noted to be declining in terms 
of your ability to perform daily activities and ambulate. It is getting more difficult for you to re-position 
yourself while in bed, but your level of function with regards to bed mobility is not provided. Additionally, the 
guideline indicates that you are required to have pressure wounds to qualify for a pressure reducing mattress. 
You are not noted to have pressure wounds or skin breakdown. You have not had flap surgery. Therefore, you 
do not meet criteria for the requested item. 
 
 
 
 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 powered pressure-reducing air mattress have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress, identified with 
code E0277.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the services are not medically 
necessary.  
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee appears to have 
reached a plateau in function. The enrollee's care needs are highly custodial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven home health physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 08, 2023. 
 
You asked the Plan to pay for the laboratory services. You say that these services were medically necessary. 
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 laboratory services 
provided on May 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frozen embryo transfer. 
 
You asked the Plan to pre-approve frozen embryo transfer. You say that you need this due to previous health 
issues. The Plan denied your request. The Plan says this is not considered treatment of a disease and is not 
covered. 
 
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 frozen embryo transfer. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found cryopreservation and transfer of embryos is not considered treatment of a disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of frozen embryo transfer have not been met. Therefore, we decided that the Plan 
does not have to pre-approve frozen embryo transfer.
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 needs long term acute care 
to regain maximum function. The Plan denied your request. The Plan says the records do not show that the 
enrollee will get better with LTACH care. The Plan says care is being provided 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 it is documented throughout that the enrollee is minimally responsive and has a poor 
prognosis. It appears that the medical team agrees the enrollee is more hospice appropriate, but family wishes 
to pursue the most aggressive level of care.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair with single power option 
and accessories (K0856, E2361, E2300, E1002, E1225, K0108, E0955, E1028, E2607, E2377, E2313, E2311). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with single power option and accessories. 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 power mobility devices 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 a group 3 power wheelchair with single 
power option and accessories. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found the enrollee does not have high risk for skin breakdown, use a catheter intermittently, have 
spasticity or require an alternative means of managing power drive. 
 
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 group 3 power wheelchair with single power option and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with 
single power option and accessories (K0856, E2361, E2300, E1002, E1225, K0108, E0955, E1028, E2607, 
E2377, E2313, E2311).