Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital services provided on September 4, 2019, through 
September 29, 2019. 
 
You asked the Plan to pay for the hospital services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this provider is a non-Medicare 
approved/certified freestanding emergency facility. 
 
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 hospital services provided on 
September 4, 2019, through September 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from July 1, 2019, through 
December 2, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
physician's services. 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 from July 1, 2019, through 
December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable liquid oxygen system (E0433).

You asked the Plan to pre-approve a portable liquid oxygen system (E0433). You say that the requested Portable liquid oxygen system (E0433) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Portable liquid oxygen system (E0433).

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 

2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;

3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;

4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or Erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

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 portable liquid oxygen system (E0433). Our reviewer says that the enrollee does not meet criteria for the requested Portable liquid oxygen system (E0433). Our physician reviewer found coverage criteria for a liquid oxygen system, for purposes of travel, are not met. The medical records do not include documentation of the need for supplemental oxygen. There is one oxygen saturation measurement of 91% unclear whether that is breathing room air. Medicare criteria for oxygen need include a saturation of 88% or less. In addition, the enrollee already has a stationary oxygen concentrator and a portable oxygen system; the requested DME would duplicate that, which is not covered by Medicare. Also, Medicare does not cover portable oxygen systems specifically for travel outside the home. The requested liquid oxygen system is 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 a portable liquid oxygen system (E0433) have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable liquid oxygen system (E0433).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided from May 1, 2020, through 
December 31, 2020. 
 
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the care 
received must have been requested and authorized at the in-network benefit level before services were 
rendered. All claims have been processed correctly according to the health plan benefits. 
 
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 providers in this case are not a network providers 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 outpatient services provided from May 1, 2020, through 
December 31, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 was admitted for surgical treatment of a jaw infection. Medical problems are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.

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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to an inpatient rehabilitation facility for rehabilitation. It is documented that the enrollee has open areas on her left buttock and coccyx. The enrollee is ambulating in an overhead harness system with 1 person to steady the rolling walker and 1 person to advance her lower extremities. The enrollee is progressing toward her occupational therapy goals.

Based on the documentation provided, the enrollee does not require skilled nursing services. The enrollee does require skilled therapy services. However, the necessary services may be provided in the IRF. The documentation does not support that transfer to a SNF is 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781).

You asked the Plan to pay for the progressive lenses. You say that the Plan should provide reimbursement in the amount that is normally covered for a pair of glasses. The Plan denied your request. The Plan says progressive lenses are not covered under your Plan.

The Plan must follow Medicare rules. The rules say that Medicare covers one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. Overed eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare. Any upgrades including progressive lenses are not covered.

You asked the Plan to pay for progressive lenses following cataract surgery. Upgraded lenses are not covered by the Plan. The record shows that the out-of-network provider did not bill a separate charge for standard lenses. Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and eye refraction services provided on 
October 22, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the eye exam and eye refraction services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 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 the eye exam and eye refraction services provided 
on October 22, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the ambulance transport you received on 
September 28, 2020, and the walker you received on October 7, 2020. 
 
You asked the Plan to waive the cost sharing for the ambulance transport and the walker. You say that you 
don't believe you should have to pay this cost sharing because these services were needed as the result of 
complications during a procedure. The Plan denied your request. The Plan says you were charged these cost 
sharing amounts 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 $250 
copayment for ambulance services and 20% coinsurance for durable medical equipment.  
 
Records show that you were transported to the emergency room on September 28, 2020, because you had 
shortness of breath following a colonoscopy. On October 7, 2020, you received a walker as well. You have 
been asked to pay a $250 copayment for the ambulance transport and 20% coinsurance for the walker. The 
walker falls within the durable medical equipment benefit category. This means that you have been asked to 
pay the correct amounts based on your contract with the Plan. These cost sharing amounts apply regardless of 
the reason for the services. 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 sharing for the ambulance 
transport you received on September 28, 2020, and the walker you received on October 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar-sacral orthosis (L0637).

You asked the Plan to waive the coinsurance for the lumbar-sacral orthosis. You say that you believe the Plan should completely cover this item. The Plan denied your request. The Plan says the cost share has processed correctly and no reimbursement is due.

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 durable medical equipment.

You have been asked to pay a total cost share of $164.55 for the lumbar-sacral orthosis ($822.73 Medicare allowed amount x 20% coinsurance). This item falls within the durable medical equipment 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 lumbar-sacral orthosis (L0637).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal protective equipment and periodontal maintenance.

You asked the Plan to pay for the personal protective equipment and periodontal maintenance. You say that you believe these services should be covered. The Plan denied your request. The Plan says periodontal maintenance is allowed one time in a 6-month period. The Plan also says the personal protective equipment is only considered for payment if it is accompanied by a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, periodontal maintenance is limited to 1 every 6 months. The record shows that you received periodontal maintenance and your periodontal maintenance benefit had been exhausted. The record shows the periodontal maintenance is not covered, which is why the personal protective equipment is not covered. Therefore, we decided that the Plan does not have to pay for the personal protective equipment and periodontal maintenance.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).

You asked the Plan to pre-approve the additional mileage. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request exceeds the allowable transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at your request, the records in the case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your request to the Plan was for an additional 99 miles for each one-way trip, 174 miles in total. However, the Plan provides coverage for only 75 miles of driving distance for each one-way trip. Your request exceeds the allowable transportation benefit. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation (A0170).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that a claim for Cardiovascular Disease Screening shall be submitted with specific CPT codes.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment panel have not been met. Specifically, this testing is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdomen x-ray provided on November 
11, 2020. 
 
You asked the Plan to waive the copayment for the abdomen x-ray. You say that you have never paid a fee for 
radiology before. You say that you were told there was only a $5 copayment at the time of the visit. The Plan 
denied your request. The Plan says the copayment applied 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 
copayment for x-rays and ultrasounds. 
 
You have been asked to pay $18.46, which is less than the standard $20 copayment for the abdomen x-ray. The 
abdomen x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 abdomen x-ray provided on November 11, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5261) provided on December 9, 2020. 
 
You asked the Plan to pay for the hearing aid. You say that you called ahead to make sure that hearing aids 
were covered by your Plan. The Plan denied your request. The Plan says hearing aids are covered by the 
supplemental hearing benefit; however, you did not go through the Plan's hearing vendor to request these 
supplemental services as required by the contract. The Plan states that they have a record of a call where the 
non-contracted provider called to verify your benefits. The provider was advised that they were non-contracted 
and that your benefits must be provided by the Plan's contracted vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when they are provided by the Plan's contracted vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5261) provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the protective headgear (A8000) provided on October 15, 
2020. 
 
You asked the Plan to pay for the protective head gear. You say that you would like reconsideration because 
this equipment is medically necessary for the member's wellbeing and protection. The Plan denied your 
request. The Plan says this equipment does not meet the definition of durable medical equipment. 
 
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 pay for the protective headgear (A8000) provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308, 99305) provided on October 24, 
2019 to November 15, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary. The 
Plan denied your request. The Plan says these services were 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 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 nursing facility care (99308, 99305) provided on 
October 24, 2019 to November 15, 2019 by an out of network (OON) provider.