Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260 x 4). 
 
You asked the Plan to pre-approve the osseous surgery. You say that you cannot get on a payment plan due to 
being on a fixed income. The Plan denied your request. The Plan says osseous surgery is not listed as 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, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
osseous surgery (D4260 x 4).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound examination of the heart 
provided on March 16, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound examination of the heart. You say that you 
disagree with the charges because you normally only owe a $45 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 $200 
copayment for ultrasounds.  
 
You have been asked to pay a $200 copayment for an ultrasound examination of the heart. An ultrasound 
examination of the heart 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 an ultrasound examination of the heart 
provided on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on January 16, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because the Plan 
directed you to this provider. The Plan denied your request. The Plan says this provider is not in-network with 
the Plan. 
 
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 when you have received a referral from your doctor.  
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Specifically, the record does not show that you 
received a referral from your provider for these services. Additionally, the documentation submitted does not 
include sufficient information to determine if the hearing aids were medically reasonable and necessary. 
Therefore, we decided that the Plan does not have to pay for hearing aids provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglass frames you received on June 5, 2020. 
 
You asked the Plan to pay for the frames. You say that you were told that you would be reimbursed. The Plan 
denied your request. The Plan says this is not covered under your plan. 
 
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. The Plan does not covered any lens or frame upgrades, including deluxe frames. 
 
We looked at the file and the Plan's rules. The eyeglass frames you received were considered deluxe frames. 
The Plan does not cover deluxe frames. You are responsible for the cost of the upgrade. Based on this 
 
 
information, we decided that the Plan's rules for coverage of the frames have not been met. Therefore, we 
decided that the Plan does not have to pay for the eyeglass frames you received on June 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) provided on 
February 27, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for domiciliary visit. You say that the services rendered were medically necessary. 
The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-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 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 domiciliary or rest home visit (99335) 
provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the criteria was not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 enrollee's medical condition has stabilized, and the documentation does not 
support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tab 2.5mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no pharmacy benefit with this 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 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 Methotrexate tab 2.5mg for 
the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cataract surgery (66984) performed on 
October 28, 2018. 
 
You asked the Plan to waive the copayment for a cataract surgery. You say that surgery of both eyes cannot be 
done on the same day and you should only have been charged once. The Plan denied your request. The Plan 
says the correct copayment 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 $360 
copayment for each Medicare-covered visit to an ambulatory surgical center.  
 
You have been asked to pay a $360 copayment for a cataract surgery. A cataract surgery falls within the 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers" 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 a cataract surgery (66984) 
performed on October 28, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller and related accessories for a 
power mobility device (E2377, E2313, E2311). 
 
You asked the Plan to pre-approve the controller and accessories. You say that the controller is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that expanded controllers are covered when medically 
necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the controller and accessories. Our 
reviewer says that the controller is not medically necessary. Our physician reviewer found the patient's strength 
and functional ability are sufficient to allow her to control any power options through their own individual 
switches. 
 
 
 
 
 
 
 
 
 
 
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 controller and accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller and related accessories for a power mobility device 
(E2377, E2313, E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair for the enrollee. 
 
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a bath/shower chair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis LT,RT (L1851x2) suspension sleeve, LT, 
RT (L2397x2) provided November 27, 2019. 
 
You asked the Plan to pay for the orthoses. You say that please find the medical documentation which shows 
that these services are medically necessary. The Plan denied your request. The Plan says the records do not 
support the service billed. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. 
The documentation submitted did not include an itemized shipping/billing invoice to indicate the specific 
supplies had been delivered, or proof of delivery to corroborate with the delivery ticket. The delivery ticket also 
has missing information. The record shows that the Plan made several attempts to obtain the necessary 
documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis 
LT,RT (L1851x2) suspension sleeve, LT, RT (L2397x2) provided November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture (36415), low osmolar contrast 
material (Q9967), computed tomography (CT) of abdomen (74178), and assay of creatinine (82565) provided 
on March 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for routine venipuncture, low osmolar contrast material, CT scan of abdomen, and 
assay of creatinine. You say that the services should be reconsidered for payment. The Plan denied your 
request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-
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 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 routine venipuncture (36415), low osmolar 
contrast material (Q9967), computed tomography (CT) of abdomen (74178), and assay of creatinine (82565) 
provided on March 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy and psychiatric diagnostic evaluation 
(90837, 90791) provided on May 8, 2020, through June 24, 2020. 
 
You asked the Plan to pay for the psychotherapy and psychiatric diagnostic evaluation. You say that you would 
like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this service 
is not covered by Medicare or your plan. 
 
The Plan must follow Medicare rules. Medicare rules say that Part B covers mental health services with 
specific types of health professionals.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, the requested provider is a Licensed Mental Health 
Counselor. This provider type is not eligible for Medicare coverage of mental health services. Therefore, we 
decided that the Plan does not have to pay for the psychotherapy and psychiatric diagnostic evaluation (90837, 
90791) provided on May 8, 2020, through June 24, 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for hip replacement after a fall. 
Your medical problems are stable. There are no identified problems that need inpatient medical management. 
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy but it does not support a need for an 
intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 waive the copayment for specialist services provided by a 
participating provider on February 14, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you think the Plan should pay 
for some of this. The Plan denied your request. The Plan says the correct copayment has been 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 $20 
copayment for physician/practitioner services/specialist.  
 
You have been asked to pay $10.36 which is less than your copayment amount of $20 for specialist services. 
Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on February 
14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 27, 2020 to June 4, 
2020 by an out of network provider. 
 
You asked the Plan to pay for speech/hearing therapy services. You say that the enrollee provided Medicare 
information, as primary insurance, not the Plan information. The Plan denied your request. The Plan says you 
did not request prior authorization. 
 
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 on May 27, 2020 to June 4, 2020 by an out of 
network provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on July 2, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you are on a limited 
income and you cannot afford this copayment. The Plan denied your request. The Plan says you were charged 
this copayment 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 $260 
copayment for ambulance services.  
 
You have been asked to pay a $260 copayment for the ambulance services. 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 you received on July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessories. 
 
You asked the Plan to pre-approve the requested accessories. The Plan denied your request. The Plan says the 
requested services 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.   
 
The file shows that a USB charger, switch operated fender lights, and push handles were requested. The items 
at issue do not serve a purpose that is primarily medical in nature. Based on this information, we decided that 
the Medicare coverage rules have not been met.  
 
 
The file shows that an expandable control system was requested. 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 
requested system. Our physician says that the enrollee has adequate strength in his right upper extremity that is 
sufficient to control any power options through their own individual switches. Based on this information, we 
decided that the Medicare coverage rules have not been met. Therefore, we decided that the Plan does not have 
to pre-approve wheelchair accessories.