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

 
We decided that the Plan does not have to pay for the laboratory services provided on October 11, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that this is a Medicare-covered service. 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 October 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis with allograft (Minuteman device) at L3-4. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the enrollee has tried conservative 
treatments including epidural steroid injections, but these have failed to provide durable, sufficient relief of the 
enrollee's pain and other symptoms. The Plan denied your request. The Plan says this procedure is not 
supported by research 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 a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are multiple alternate pain generators plausibly significantly contributing to the 
clinical condition that have not been fully documented as having been excluded and/or ruled out.  
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 Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve arthrodesis with allograft (Minuteman device) at L3-4.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assistant surgeon services provided on January 3, 2023. 
 
You asked the Plan to pay for assistant surgeon services. You say that the denial should be reversed and 
additional payment made. The Plan denied your request. The Plan says an assistant surgeon is not payable for 
these procedure codes. 
 
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, 
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current 
Procedural Terminology (CPT) codes 33241, 33249, 33244, and 33225. The Medicare Fee Schedule Database 
contains a surgical indicator of 1 for these codes. This means that Medicare has determined that an assistant 
surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare 
coverage criteria for assistant surgeon services have not been met. Therefore, we decided that the Plan does not 
have to pay for assistant surgeon services provided on January 3, 2023.
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 will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the IRF services requested 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services provided on March 09, 2023. 
 
You asked the Plan to pay for the podiatry 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 podiatry services 
provided on March 09, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MyoPro Motion G orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion G. You say that this is the enrollee's best opportunity for 
regaining meaningful use of the limb. The Plan denied your request. The Plan says this is 
experimental/investigational. 
 
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 MyoPro Motion G. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is insufficient evidence in the literature that the MyoPro orthosis will improve 
long-term outcomes for this enrollee. The MyoPro is not the standard of care for the enrollee's condition or in 
widespread use.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G have not been met. Therefore, we decided that the Plan does 
not have to pre-approve MyoPro Motion G orthotic device.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen. 
 
You asked the Plan to pre-approve a CT scan. You say that you are requesting a fast appeal for the denial of a 
CT scan to rule out an abdominal hernia prior to surgery. You say any hernia repair would be medically 
necessary and unrelated to the tummy tuck which is a cosmetic procedure. The Plan denied your request. The 
Plan says the request is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the enrollee has no physical signs of an 
abdominal hernia and no ultrasound of the anterior abdominal wall has been done. As such, a CT scan of the 
abdomen would be a screening procedure and a non-covered benefit. 
 
 
 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 CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a computed tomography (CT) scan of the abdomen.
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 is unsafe to discharge home at this time. 
The Plan denied your request. The Plan says the IRF services you are requesting 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 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. While the medical record supports a need for physical and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis on January 02, 2023, to January 
14, 2023.  
 
You asked the Plan to waive the coinsurance for dialysis. You say that every other month the plan has covered 
the entire amount of dialysis invoices, why is this month any different? 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-covered benefits for outpatient dialysis treatment. Covered services include 
outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as 
explained in Chapter 3), or when your provider for this service is temporarily unavailable or inaccessible. For 
dates January 02, 2023, to January 13, 2023, the provider billed in the amount of $4,963 and the allowed 
amount is $418.12 for the service. $418.12 x 20% = $83.62. There were nine visits. 9 x $83.63 = $752.67. For 
date of service January 14, 2023, Plan allowed $418.12 less $47.42 patient responsibility less sequestration 
$7.41 ($370.70 x 2%) = Plan paid $363.29. For the services it's, $752.67 + $47.42 = $800.09. Therefore, results 
in the total cost shairng amount of $800.09. 
 
You have been asked to pay a 20% coinsurance for dialysis. This item/service falls within the services to treat 
kidney disease 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 dialysis on January 02, 
2023, to January 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260), a pressure-
reducing air mattress (E0277), and a pressure-reducing mattress pad (E0181). 
 
You asked the Plan to pre-approve the hospital bed, air mattress, and mattress pad. You say that you are 
requesting reconsideration of the denied authorization. The Plan denied your request. The Plan says the 
coverage criteria has not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say a semi-electric hospital bed (E0260) is covered if the beneficiary 
meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an 
immediate need for a change in body position. 
 
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 hospital bed, air mattress, and 
mattress pad. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the semi-electric hospital bed is not medically 
necessary as the documentation does not reveal that you require frequent changes in body position and/or have 
an immediate need for a change in body position. The documentation does not show that you require body 
positioning in ways not feasible with an ordinary bed that require the head of the bed to be elevated more than 
30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with 
aspiration, or that you require traction equipment, which can only be attached to a hospital bed. The requested 
air mattress and mattress pad exceeds your medical needs as the semi-electric is not necessary and the 
documentation does not show evidence of a pressure ulcer. 
 
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 hospital bed, air mattress, and mattress pad have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260), a pressure-reducing 
air mattress (E0277), and a pressure-reducing mattress pad (E0181).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 22, 2023. 
 
You asked the Plan to pay for the office visit. You say that this service was 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 office visit provided 
on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home visit. 
 
You asked the Plan to pre-approve a home visit. You say that you suffer from herniated disks on your neck and 
two bulges on your back. You are in pain, and you would like at-home doctor's visits so that you do not have to 
leave your home to see your PCP. The Plan denied your request. The Plan says you have a network PCP who is 
responsible for providing your routine health care needs and overseeing your care. You must get approval in 
advance from your PCP, such as giving you a referral. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that when you become a member of the plan, you must choose a plan provider to be your primary 
care physician (PCP). You have a network primary care physician (PCP) who is responsible for providing your 
routine health care needs and overseeing your care. If you need certain types of covered services or supplies 
from network providers, you must get approval in advance from your PCP. 
 
You have a network PCP who is responsible for providing your routine health care needs and overseeing your 
care. If you need services or supplies from a network provider, you must get approval in advance from your 
PCP. The records show that a referral and/or clinical information was not submitted by your PCP. We found no 
exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan 
does not have to pre-approve a home visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #5 provided on November 9, 
2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist deemed it necessary to perform a 
crown.  The Plan denied your request. The Plan says the denial of the crown was correct and the alternate 
benefit of an amalgam-two surfaces for tooth #5 because there were two options of treatment, a filling, or a 
crown and the tooth can be restored with a direct restoration to treat decay/defective filling. 
 
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 the dental 
service when the services are medically necessary and reasonable.  
 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 a crown and applying the least costly 
method of an amalgam-two surface for tooth #5. Our reviewer says that the Plan was is correct to apply an 
alternative benefit based on documentation submitted. Our physician reviewer found that there was an 
alternative treatment that could have been done for tooth #5 as a more conservative treatment. Upon review of 
the clinical documentation, there is a decay noted on the x-ray. The dental provider also noted it in their clinical 
documentation. The photos and x-rays submitted do not show extensive decay or that after decay removal that 
there was not sufficient tooth structure remaining necessitating the need for a crown. Crowns are placed when 
there is extensive decay noted or when there is fracture of a tooth. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pay for a crown (D2740) for tooth #5 provided on November 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network  annual wellness visit 
provided on March 13, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network  annual wellness visit. You say that you 
disagree with the coinsurance. 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 40% 
coinsurance for out-of-network annual wellness visit. 
 
You have been asked to pay 40% coinsurance for an out-of-network  annual wellness visit. This item/service 
falls within the out-of-network annual wellness visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The total allowed amount for the  annual wellness visit is $201.92. 
You are being asked to pay $80.77 ($201.92 x 40% = $80.77). Therefore, we decided that the Plan does not 
have to waive the coinsurance for an out-of-network  annual wellness visit provided on March 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Austedo tablet. 
 
You asked the Plan to pre-approve Austedo. You say that the requested drug is a medical necessity for the 
enrollee. 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Austedo 
tablet.  
 
Benefits for Austedo 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on February 22, 2023. 
 
You asked the Plan to pay for wound care supplies. You say that there are wound care supplies that can be 
billed separately, and should not need a referral. 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 wound care supplies 
provided on February 22, 2023.