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

 
We decided that the Plan does not have to pre-approve the standard wheelchair to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of DME. The 
Plan denied your request. The Plan says there are in-network providers that can provide the DME. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the standard wheelchair to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on February 18, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that these services were medically necessary. The Plan denied 
your request. The Plan says prior authorization was not 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 lab work provided on February 18, 2020 by an out 
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Easy Stand Glider. 
 
You asked the Plan to pre-approve the Easy Stand Glider. You say that the enrollee needs this device to stand 
in an upright position to exercise and build their strength. The Plan denied your request. The Plan says the 
equipment request does not meet Medicare's definition of Durable Medical Equipment and is consider a 
convenience item. 
 
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 pre-approve the Easy Stand Glider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services provided on March 2, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that you would like reconsideration because 
the member's condition was considered time critical and the member was at risk of rapid deterioration. The 
Plan denied your request. The Plan says the member could have been safely transported by ground ambulance. 
 
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the documentation does not support that the transportation duration or type posed a threat to the 
member. Our physician reviewer found the sending facility could have stabilized the member then sent via 
ground ambulance. 
 
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 air ambulance services have been met. Therefore, we decided that the Plan 
does not have to pay for air ambulance services provided on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from 10AM on 
January 30, 2020 to January 31, 2020. 
 
You asked the Plan to pay for the continued inpatient hospital care. You say that the enrollee requires all 
services rendered during the hospital stay. The Plan denied your request. The Plan says payment is made for all 
services rendered prior to 10AM on January 30, 2020. Beyond that time, the enrollee was stable for transfer, 
but the plan was not notified to request authorization for post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 continued inpatient hospital care. Our 
reviewer says that the documentation supports that the enrollee was stable for transfer on the morning of 
January 30, 2020. Our physician reviewer found the enrollee presented to the emergency department on 
1/29/20 with a diagnosis of an ST segment elevation myocardial infarction.  She was emergently treated in the 
cardiac catherization lab and had a stent placed in her right coronary artery. At the time of the evaluation on the 
morning of January 30, she was stabilized and approval for post-stabilization care should have been requested. 
 
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 continued inpatient hospital care have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital services provided from 10AM on January 30, 2020 
to January 31, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee has a lump on her back, and you are 
trying to figure out if this is sub-muscular or lipoma versus sarcoma, and this is not for screening. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because the 
enrollee does not meet the criteria for this CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CT scan. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found the presence of a 
firm soft tissue mass is very concerning for soft tissue malignancy. The method of choice for evaluation of such 
a mass is either Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) with contrast. Based 
upon the physical location of this firm mass, below the right scapula, the requested CT of the thorax with 
contrast is appropriate and 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a Computed Tomography (CT) scan of the chest.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tubing and supplies (S1015, S8301) provided on March 9, 
2020. 
 
You asked the Plan to pay for tubing and supplies. You say that these items should be covered. The Plan denied 
your request. The Plan says these items were not billed correctly. 
 
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 S1015 and S8301 are not supported in the medical record. Specifically, these codes 
have a status indicator of I. Medicare uses another code for reporting of, and payment for these services. 
Based on this information, we decided that Medicare rules for coverage of tubing and supplies have not been 
met. Therefore, we decided that the Plan does not have to pay for tubing and supplies (S1015, S8301) provided 
on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer. 
 
You asked the Plan to pre-approve the Vertiflex Superion Interspinous Spacer. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says 
medical studies have not proven that this device is helpful for the treatment of the member's condition. 
 
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 Vertiflex Superion Interspinous 
Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this device is experimental and more research is needed to 
show its safety and efficacy. 
 
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 Vertiflex Superion Interspinous Spacer have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ER visit provided on May 7, 2020. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges. 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 $120 
copayment for emergency care.  
 
You have been asked to pay a $120 copayment for an ER visit. An ER 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 an ER visit provided on May 7, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on December 13, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for an injection. You say that these services were medically necessary. The Plan 
denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring 
providers are also out-of-network. 
 
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 injection provided on December 13, 2019 by an 
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis provided on June 10, 2020. 
 
You asked the Plan to pay for the prophylaxis. You say that your plan booklet shows a $0 copayment for 
exams, cleanings, x-rays, and fluoride with in-network or out-of-network coverage. You say that you should be 
reimbursed the additional $86. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 Plan is only obligated to pay the 
allowed amount for a prophylaxis from an out-of-network provider. You are responsible for the remaining 
amount. Therefore, we decided that the Plan does not have to pay for the prophylaxis provided on June 10, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telephone services provided by a specialist 
on June 10, 2020. 
 
You asked the Plan to waive the copayment for telephone services provided by a specialist. You say that you 
asked three questions and feel that you should not 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 $45 
copayment for specialist services.  
 
You have been asked to pay $15, which is less than the $45 copayment for telephone services provided by a 
specialist. Telephone services provided by a specialist fall within the physician/practitioner services, including 
doctors office visits 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 telephone services 
provided by a specialist on June 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on January 31, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 20, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
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 subsequent nursing facility care provided on December 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 8, 2019 to December 
31, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the OON medical services. You say that the reason you stepped out of network 
was because the Plan had no available therapists that were close to where you lived during the time you needed 
to start therapy. You say that the Plan has now authorized visits with this out of network provider. The Plan 
denied your request. The Plan says you did not have a prior authorization for a monthly subscription with a 
non-contracted provider. The Plan says that this was not plan-directed care and that you referred yourself out of 
network without 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 did not pre-approve the 
OON care that was provided on the dates of service in dispute. 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 June 8, 2019 to December 31, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the insertion of a permanent pacemaker 
provided on July 16, 2020. 
 
You asked the Plan to waive the copayment for the insertion of a permanent pacemaker. You say that you were 
quoted a $380 copayment and disagree with the charges. 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 $450 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay a $450 copayment for the insertion of a permanent pacemaker. The insertion of a 
permanent pacemaker 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 the insertion of a permanent pacemaker provided on July 16, 2020.  
 
We note your complaint that you were misquoted. Your complaint is a grievance that must be answered by the 
health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on April 29, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 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 a domiciliary, rest home visit provided on April 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis coded L0650 provided on APril 3, 
2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the claim is not payable as billed. 
 
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 CPT Code Manual definition of code L0650 is lumbar-sacral orthosis, sagittal-coronal control, 
with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, 
lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on 
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen 
design, prefabricated, off-the-shelf. 
 
We find that CPT code L0650 is not supported in the medical record. Specifically, the documentation 
submitted indicates that the items were administered by a health care provider other than the billing health care 
provider. There is no billing provider name on the billing invoice. Based on this information, we decided that 
Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Therefore, we decided that the 
Plan does not have to pay for the lumbar-sacral orthosis coded L0650 provided on April 3, 2020.