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

 
We decided that the Plan does not have to pay for the CPAP device and accessories provided on January 27, 
2020 to February 27, 2020 by an out of network provider. 
 
You asked the Plan to pay for the CPAP device and accessories. You say that the CPAP was medically 
necessary. The Plan denied your request. The Plan says there is no network deficiency for this service. 
 
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 CPAP device and accessories provided on 
January 27, 2020 to February 27, 2020 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustable hospital bed, non-covered service, support 
pillow, leak proof undergarment and tax provided on February 27, 2019. 
 
You asked the Plan to pay for the equipment. You say that you would like reconsideration because the 
member's reimbursement claim was denied. The Plan denied your request. The Plan says all requests for 
member reimbursement must be filed within 12 months of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the equipment was not filed until April 9, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the adjustable hospital bed, non-covered service, support pillow, leak proof 
undergarment and tax provided on February 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye exam provided on June 12, 
2020. 
 
You asked the Plan to waive the copayment for the medical eye exam. The Plan denied your request. The Plan 
says there is a $40 copayment per visit for Medicare-covered eye exams to diagnose and treat diseases of the 
eye, including an annual glaucoma screening for members at high risk. 
 
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 $40 
copayment for Medicare-covered vision care.  
 
You have been asked to pay $40 copayment for the medical eye exam. the medical eye exam falls within the 
Medicare-covered vision 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 a medical 
eye exam provided on June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the records provided support the need for the requested 
drug. The Plan denied your request. The Plan says the information submitted does not meet the medical 
necessity guidelines for coverage. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Prolia. Our reviewer says that the 
request to skip Zoledronic Acid and take Prolia as first line therapy is not medically reasonable or necessary. 
Our physician reviewer found the enrollee has osteoporosis and requires bisphonate therapy. She has not had a 
fracture yet but is at increased risk of having one. She has not tried Zoledronic acid and does not have a 
documented contra-indication to Zoledronic Acid. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 6, 2018. 
 
You asked the Plan to pay for the testing services. You say that services were provided in good faith. The Plan 
denied your request. The Plan says those with only a family diagnosis is not considered necessary for genetic 
testing. 
 
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 documentation shows the enrollee received hereditary breast and ovarian cancer testing. The test at issue 
was requested for screening purposes. Medicare does not cover this test solely for screening purposes. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on November 6, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a back brace (L0648) provided on May 11, 2020. 
 
You asked the Plan to pay for a back brace. You say that this was medically necessary. The Plan denied your 
request. The Plan says the documentation did not include evidence of an established relationship between the 
member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a back brace (L0648) 
provided on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9945). 
 
You asked the Plan to pre-approve the dental item. You say that you suffer from pain during the day. You say it 
is caused by clenching your teeth at night. The Plan denied your request. The Plan says occlusal guard 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 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard 
(D9945).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forelectric stimulation therapy provided on January 28, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says that the billed code is not valid for Medicare purposes.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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forelectric stimulation therapy provided on January 28, 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 you disagree with the denial. The Plan 
denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital on October 6, 2020 with septic shock, Strep Bovis bacteremia, and ventricular 
tachycardia. He is now hemodynamically stable and is not on a ventilator. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on January 14, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 physician services provided on January 14, 
2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve permanent crowns (D2740) for teeth # 4, 5, and 30. 
 
You asked the Plan to pre-approve the dental service. You say that you are upset that you got temporary 
crowns. You say that you want to go to another office to get permanent crowns. You also say that your 
temporary crowns are painful. The Plan denied your request. The Plan says crowns are covered once per tooth 
every 5 plan years. The Plan also says the frequency limit for a crown for teeth # 4, 5, and 30 has been 
exceeded. 
 
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 and crowns are a covered service, the 
frequency limit of once per tooth every 5 plan years. The record shows that you received crowns for these teeth 
on October 29, 2019. Therefore, we decided that the Plan does not have to pre-approve permanent crowns 
(D2740) for teeth # 4, 5, and 30.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for an exception to the mileage limit for routine 
transportation. 
 
You asked the Plan to provide coverage for this exception. You say that this exception is necessary. The Plan 
denied your request. The Plan says exceptions are not made to supplemental benefits. 
 
Medicare does not cover routine transportation. The Plan covers 24 one-way trips that are not to exceed 50 
miles one way. Neither Medicare nor the Plan makes exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to provide coverage for an exception to the mileage limit for routine 
transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on November 19, 2019 by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the International Classification of Diseases 
codes are valid per CMS. The Plan denied your request. The Plan says the services were rendered by a non-
network provider. The Plan also says that the enrollee was referred by another non-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 laboratory services provided on November 19, 
2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit billed for services provided on June 17, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the 
evaluation and management service was billed with an incorrect place of service. 
 
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 99205 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of 
care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of 
moderate to high severity. 
 
We find that the enrollee received care in the emergency department. The services at issues were not billed 
with a valid emergency department code. Based on this information, we decided that Medicare rules for 
coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay 
for the office visit billed for services provided on June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric services. 
 
You asked the Plan to pre-approve the inpatient psychiatric services. You say that additional inpatient 
psychiatric treatment is medically necessary. The Plan denied your request. The Plan says the enrollee is 
medically stable and can be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric services. Our 
reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was 
admitted to the acute inpatient psychiatric hospitalization on September 16, 2020. The enrollee had a diagnosis 
of dementia with behavioral disturbance. It was not expected this enrollee would improve in a reasonable 
period of time for the dates in question, as she did not have suicidal or homicidal ideation noted and no 
auditory or visual hallucinations. It did not appear medically necessary and reasonable to have psychiatric care 
provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she 
did not have dangerousness to self or others but was compliant with her treatment. It did not appear that the 
services were reasonably expected to improve the enrollees condition or for the purpose of diagnosis beyond 
the date in question. I am unable to find an individualized treatment plan however the entire chart is not 
 
 
present. Based upon review of the records provided, the admission of this enrollee does not meet the criteria for 
continued acute inpatient mental health treatment for the dates in question of October 5, 2020, forward as the 
enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual 
hallucinations and was cooperative/compliant with treatment. 
 
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 inpatient psychiatric services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lift recliner purchased on June 26, 2020. 
 
You asked the Plan to pay for the recliner. You say that this should be paid for. The Plan denied your request. 
The Plan says this chair is not primarily intended for medical use, and is useful in the absence of illness. 
 
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 a lift recliner purchased on June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe total electric hospital bed (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that you are unable to use the semi-electric bed that is covered. You need the total electric hospital bed due to your ongoing medical conditions.The Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvethe total electric hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care. 
 
You asked the Plan to pay for inpatient hospital care. You stay that the entire say and level of care was 
appropriate as well as medically reasonable and necessary The Plan denied your request. The Plan says prior 
authorization must be obtained for services rendered by an out-of-network provider. 
 
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 inpatient hospital care. Our reviewer says 
that post-stabilization care services were not medically reasonable or necessary. Our physician reviewer found 
the treating physician did not document that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on December 21, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not submitted with an 
appropriate primary diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary].  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Specifically, this claim was billed with diagnosis code 
I31.4.Per the ICD-10 guidelines, this diagnosis code has a "code first" note meaning the underlying condition 
code should be listed first. Therefore, we decided that the Plan does not have to pay for the anesthesia services 
provided on December 21, 2020.