Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator purchased July 14, 2020. 
 
You asked the Plan to pay for the portable oxygen concentrator. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage was not met. 
 
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 pay for the portable oxygen concentrator. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the resting and exercise 
oxygen saturation of 95% on room air indicates the patient would not benefit from supplemental oxygen. 
Therefore, the request 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 portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pay for the portable oxygen concentrator purchased July 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision refraction services received on October 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction. 
 
The services you asked the Plan to pay for are considered refraction services. Therefore, we decided that the 
Plan does not have to pay for vision refraction services received on October 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bridge for teeth #14, 15, and 16.

You asked the Plan to pre-approve the bridge. You say that a bridge will allow for the enrollee's teeth to retain
proper alignment. You say that if the enrollee's teeth shift, it could cause future issues. You also say that a
bridge is a good restorative option as only 1 tooth is missing and a partial cannot be worn. The Plan denied
your request. The Plan says the submitted narrative fails to indicate or support any specific physical or
psychological condition that preclude the use of a removable prosthesis if, in fact, there were a significant
occlusal dysfunction requiring a prosthesis.

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. The Plan covers the bridge
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 pre-approve the bridge. Our reviewer says that the
bridge does not meet the criteria for coverage. Our physician reviewer found the provided documentation
shows that tooth #15 is still present. The reviewer found that a bridge in that area would not be possible as
there is no missing tooth. Therefore, the reviewer found that there is no necessity for the requested procedures
for teeth #14, 15, and 16.

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 bridge have not been met. Therefore, we decided that the Plan does not have
to pre-approve a bridge for teeth #14, 15, and 16.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 2, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not informed that 
you would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct 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 $245 
copayment for ambulance services.  
 
You have been asked to pay a $245 copayment for ambulance services. Ambulance services fall within the 
ambulance 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 copayment for ambulance services 
provided on October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic 2/1.5ml injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is denied as a benefit exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic 2/1.5ml injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction services provided on October 7, 2020. 
 
You asked the Plan to pay for the services provided. You say that the provider is considered an in-network 
provider. The Plan denied your request. The Plan says the provider is not a vision care provided. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. 
 
We looked at the file and the Plan's rules. The records do not show that the provider in this case is listed as a 
Plan vision care provider. Based on this information, we decided that the Plan's rules for coverage of have not 
been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on 
October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health services provided on September 23, 
2020. 
 
You asked the Plan to pay for the inpatient mental health services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says there were network providers available. 
 
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 services at issue in this appeal. The Plan did not pre-approve the service 
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 inpatient mental health services provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided July 13, 2019 to July 
14, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that your records indicate the claim was fully 
denied due to lack of medical necessity for inpatient stay. The physician felt the inpatient admission was 
medically necessary. The Plan denied your request. The Plan says the place of service is inappropriate or 
invalid for the services rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the provider is seeking payment for inpatient hospital services. However, the claim was billed with 
the place of service indicated as outpatient. A corrected claim must be submitted. Based on this information, 
we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital services provided July 13, 2019 to July 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-
rays, prophylaxis, and topical application of fluoride varnish provided on August 6, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not advised that this provider was no 
longer accepting Medicare coverage. The Plan denied your request. The Plan says these services were rendered 
by a provider that has opted out of Medicare. 
 
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, the requested items or services are not 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the periodic oral evaluation, complete series of intraoral x-rays, prophylaxis, and 
topical application of fluoride varnish provided on August 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
September 30, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee has a history of squamous 
cell skin cancer and breast cancer. No records were provided for review to determine if the PET scan was for 
initial treatment, follow-up, or surveillance. The records do not support that the scan was 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 pay for the positron emission tomography (PET) scan rendered on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for the services provided. You say that you believed the policy would allow services outside the immediate network. The Plan denied your request. The Plan says the claim was processed correctly.

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 in this case is not a network provider with the Plan. The Plan had network providers available to provide the services at issue in this appeal. The Plan contract says that prior authorization is required for certain outpatient diagnostic tests and services. 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 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac hereditary assessment.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are non-covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The testing was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiac hereditary assessment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (51798, 81003, 99214).

You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 $15 copayment for lab tests.

You have been asked to pay the allowable amount of $13.13 for the lab services. The lab services fall within the lab tests benefit category. The allowable amount is less than the $15 copayment listed in the Evidence of Coverage. 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 lab services (51798, 81003, 99214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services and durable 
medical equipment (DME) provided from August 17, 2020, through November 13, 2020. 
 
You asked the Plan to waive the copayment for the outpatient hospital services and DME. You say that you are 
requesting help to pay these bills. You do not have any extra money after food and medical. The Plan denied 
your request. The Plan says the claims were processed, and the correct cost share was applied per the Evidence 
of Coverage. 
 
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 $784 
20% of the cost for each covered item for DME, $25 copay for each covered x-ray, 15% of the total cost of the 
service up to $200 for each covered outpatient hospital service.  
 
You have been asked to pay $784 for the outpatient hospital services and DME. The outpatient hospital 
services and DME falls within the durable medical equipment (DME) and related supplies, Outpatient 
diagnostic tests and therapeutic services and supplies, and Outpatient hospital 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 copayment for the outpatient hospital services and durable medical 
equipment (DME) provided from August 17, 2020, through November 13, 2020.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says LTACH care is not medically necessary.

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 appears that the patient is improving and may require only short term additional acute care services including basic wound care and oxygen monitoring which can safely be administered at the current facility. The patient does not require any services at the LTACH that are not already available at the current facility. In addition, there are no services at the LTACH that the patient requires that are not already available and covered at the current facility.

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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 1, 2020 to September 
11, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visits. You say that you thought you had a prior authorization on file for 
these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because this provider is out-of-network with the Plan and you could have been treated by an in-network 
provider. 
 
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 medical services provided on July 1, 2020 to 
September 11, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 14, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the fifth positionof the HIPPS code is billed 
with a value of S for non-routine supplies (NRS) and no revenue codes 027x with NRS wasbilled. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include a valid HIPPS code. The fifth position indicates non-routine supplies, but the 
billed claim does not include a revenue code for these supplies. Therefore, we decided that the Plan does not 
have to pay for the home health services provided to the enrollee from December 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve Freestyle Libre. You say that the Freestyle Libre device is necessary for the 
enrollee's condition. The Plan denied your request. The Plan says they have already approved the preferred 
continuous glucose monitor. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. 
 
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 Freestyle Libre. Our reviewer says that 
the service is not medically necessary and reasonable. Our physician reviewer found the patient is a 66-year-old 
male with diabetes mellitus who had been using Dexcom without medical issues. Cost differences motived the 
patient to submit a claim for Freestyle Libre CGM instead. It is not medically necessary that the Libre be used 
over the Dexcom as there was no report of physical intolerance or difficulty physically with using this device 
and sensors. In addition, it would be safe and reasonable for the patient to continue to use the Dexcom. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Freestyle Libre have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Freestyle Libre continuous glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for X-Ray exam. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 medical services provided by an out of network (OON) provider.