Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pay for the hospital bed with mattress. We decided that the Plan does not have
to pay for sales tax (S9999) of $98.84.
You asked the Plan to pay for the hospital bed with mattress. You say that you are not able to pay $300 a
month to rent a bed so you went to a local mattress store and found an adjustable bed frame and mattress for
$1,198 and now it is being denied. The Plan says that reimbursement was approved for a hospital bed with
mattress (E0250) in the amount of $81.89. Sales tax (S9999) is not covered by Medicare.
We decided that the Plan has to pay for the hospital bed with mattress.
The health plan contact says that you must pay 20% coinsurance. Therefore, you are responsible for $239.60
($1198 x 20% = $239.60) and the correct reimbursement amount per the plan contract is $958.40 ($1198 -
$239.60 = $958.40) .
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 20% for
the hospital bed with mattress. Therefore, we decided that the Plan has to pay for the hospital bed with
mattress.
We also decided that the Plan does not have to pay for sales tax (S9999) of $98.84.
Sales tax is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for sales tax
(S9999) of $98.84.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair accessories (power seat elevation,
expandable controller, harness, electrical connection, urethane cushion liners).
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied
your request. The Plan says these accessories are not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
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 accessories. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable
Controller Harness are not medically necessary. The documentation does not indicate that you require a
proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head control,
etc.) other than a standard proportional joystick, a non-proportional input devices (e.g., sip and puff, head array,
etc.). You were approved for 3 or more powered seating actuators but do not require the requested devices to
control the power options. The patient does not need an expandable controller to be able to operate one or more
of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g., control of
an augmentative speech device or computer through the chair's drive control) or an attendant control. The
documentation indicates you have sufficient function and strength to control the power features through their
own individual switches therefore the requested E2311 Electronic connection, E2377 Expandable Controller
and E2313 Expandable Controller Harness are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the accessories have not been met. The cushion liners and the seat elevation
system are not considered primarily for a medical purpose. Our doctor did not find that the remaining
accessories were medically reasonable or necessary. Therefore, we decided that the Plan does not have to preapprove
power wheelchair accessories (power seat elevation, expandable controller, harness, electrical
connection, urethane cushion liners).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
February 2, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
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 $90
copayment for emergency services at an in-network emergency room.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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 copayment for the
emergency room visit provided on February 2, 2020.
Your complaint that something is not right with the hospital organization is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on November 21, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says prior authorization was not obtained.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 the drug testing provided on November 21, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an LED light package for a wheelchair for the enrollee.
You asked the Plan to pre-approve the lighting. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested lighting has been found to be not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that for durable medical equipment to be covered, it
must serve a primarily medical purpose
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 lighting. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no medical necessity for a LED light package.
We looked at this physician's review, the file, and Medicare rules. The requested item does not serve a
primarily medical purpose. Based on this information, we decided that Medicare rules for coverage of the
lighting have not been met. Therefore, we decided that the Plan does not have to pre-approve an LED light
package for a wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 18, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on January 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 2, 2019.
You asked the Plan to pay for office visit. You say that you were referred by a contracted provider to obtain
services from this provider. The Plan denied your request. The Plan says the denial of payment for this service
is correct, because this provider has opted out from Medicare coverage and is not eligible to receive payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office visit provided  on
December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on December 31, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this
service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on November 27, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network.
The Plan says that no prior authorization was obtained. The Plan says that the member's primary care physician
did not refer these services.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 outpatient visit provided on November 27,
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection services coded 87807 and
87633 provided on December 11, 2019.
You asked the Plan to pay for the infectious agent detection services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 87807 and 87633 are not supported in the medical record. Specifically, the place of
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of
service 81, however, the submitted medical documentation and/or claim history indicates that the specimen was
obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for
coverage of the infectious agent detection services have not been met. Therefore, we decided that the Plan does
not have to pay for the infectious agent detection services coded 87807 and 87633 provided on December 11,
2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 30, 2019 to
November 1, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were necessary. The Plan
denied your request. The Plan says that based on the documentation provided, coverage criteria has not been
met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the medical records provided indicate that the admitting physician expected the enrollee's
admission to span two midnights. Care provided to the enrollee was inpatient level. He had complex medical
history, required repeated doses of intravenous anti-hypertensive medications, was closely monitored for
neurologic level and seizure activities, and received hemodialysis. Inpatient services were medically necessary
and were supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from October 30, 2019 to November 1, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (POC).
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary in order to live
your normal routine of walking, shopping, and traveling. The Plan denied your request. The Plan says this is
considered a convenience item.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
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 concentrator. Our reviewer says that
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found this item,
when used for travel or other activities outside the home, is considered to be a convenience item. Medicare
does not cover convenience items. Medicare will cover a home oxygen concentrator, which the patient has. A
POC is considered not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the concentrator have not been met. Therefore, we decided that the Plan does
not have to pre-approve a portable oxygen concentrator (POC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 9, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the specialist services. You say that you would like reconsideration because the
provider took your health insurance care and charged you a copayment. The Plan denied your request. The Plan
says these services were received from an out-of-network provider and will not be covered, as stated in your
EOC.
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide 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 the medical services provided on December 9,
2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan
denied your request. The Plan says the plan has already approved eight visits.
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 additional visits. Our reviewer says
that the requested additional visits are not considered medically reasonable and necessary in this case. Our
physician reviewer found the requested ongoing therapy is generally not accepted as specific and effective
therapy for the enrollee's condition. The enrollee has had prior therapy and at this point is independent in a
home exercise program and has reported 65-70% improvement than when she started. The records not not
demonstrate that the ongoing unique skills of a professional therapist are required to safely and effectively
provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under
the supervision of a therapist. The enrollee has had extensive therapy and should be able to safely and
effectively continue her home exercise program. The requested services are not part of a maintenance program
and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design
and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
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 additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional physical therapy visits for the enrollee.