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

 
We decided that the Plan does not have to reimburse you the allowance for the eyeglasses purchased on March 
15, 2020 from an out of network provider. 
 
You asked the Plan to reimburse you the allowance for the eyeglasses. You say that this provider is less 
expensive and you are on a fixed income. The Plan denied your request. The Plan says you did not request 
authorization and the service was not an emergency or urgently needed 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 at issue in this appeal. The Plan did not pre-approve the item at issue. We 
found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does 
not have to reimburse you the allowance for the eyeglasses purchased on March 15, 2020 from an out of 
network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on March 3, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that 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 
psychotherapy services. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on March 3, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic testing rendered on June 4, 
2020. 
 
You asked the Plan to waive the copayment for these services. You say that you were quoted $10 for the 
copayment. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for diagnostic tests by a specialty physician.  
 
Review of the file shows that you received diagnostic testing of the arteries on June 4, 2020. You have been 
asked to pay a $20 copayment for these services. These services fall within the diagnostic tests by a specialty 
physician 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 diagnostic testing 
rendered on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment defined by codes L0650, 
L1851, L1971, L2397, L3170, L3916, L2960 provided to the enrollee on March 23, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claims should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice to 
indicate the specific supplies, or proof of delivery for the billed date of service. 
 
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 proof of delivery to support medical necessity for the supplies provided in 
this case. The documentation does not contain an itemized billing/shipping invoice. 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 durable medical equipment defined by codes L0650, L1851, L1971, 
L2397, L3170, L3916, L2960 provided to the enrollee on March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided March 11, 2020 to 
March 13, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically 
necessary. The Plan denied your request. The Plan says the services could have been rendered in the outpatient 
setting. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the procedure was not on the inpatient only list. The record did not show that at the 
time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care would span two midnights. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided March 11, 2020 to March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar sacral orthosis (L0650) provided on February 13, 
2020. 
 
You asked the Plan to pay for the lumbar sacral orthosis. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says there is no evidence that a provider exam 
was rendered in-person. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lumbar sacral orthosis have not been met. Specifically, the record does not include sufficient 
information to confirm that Medicare coverage has been meta. Therefore, we decided that the Plan does not 
have to pay for lumbar sacral orthosis (L0650) provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on April 13, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on April 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on March 24, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy services provided on March 24, 
2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L0650, L1971, L3170, L3916, L3960) provided on 
March 26, 2020. 
 
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied 
your request. The Plan says the file does not contain a valid proof of delivery. 
 
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 proof of delivery for the supplies provided in this case. The delivery ticket 
in the file does not corroborate the date of service these items were billed with. 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 orthotics (L0650, L1971, L3170, L3916, L3960) provided on March 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays (72070 and 72100) provided on April 28, 2020. 
 
You asked the Plan to pay for the x-rays. You say that you would like reconsideration because these x-rays 
were medically necessary. The Plan denied your request. The Plan says this service is not covered under your 
contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The Plan rules say that x-rays are excluded from 
your additional chiropractic benefit. 
 
The records show that the service at issue is not manual manipulation of the spine. Additionally, per your 
contract with the Plan, x-rays are excluded from your additional chiropractic benefit. Therefore, we decided 
that the Plan does not have to pay for x-rays (72070 and 72100) provided on April 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory services. 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 
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 laboratory services provided on February 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery services provided on 
January 23, 2019. 
 
You asked the Plan to waive the copayment for outpatient surgery services. You say that you received 
documentation from the Plan that shows you have no charges. The Plan denied your request. The Plan says the 
copayment you are being charged is correct. 
 
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 $125 
copayment for each Medicare-covered visit to an ambulatory surgical center.  
 
You have been asked to pay a $125 copayment for outpatient surgery services performed in an ambulatory 
surgical center. Outpatient surgery services 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 outpatient surgery services provided on January 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on June 28, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy services provided on June 28, 
2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic continuous glucose monitors/receiver (K0554) 
supply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided February 22, 2020. 
 
You asked the Plan to pay for the CGM receiver (monitor) and supplies. You say that kindly review the 
attached guidelines and Medical records showing the medical necessity for the billed diagnosis. The Plan 
denied your request. The Plan says the billed supply code cannot be verified. 
 
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 delivery ticket and proof of delivery for the supplies provided in this case. 
The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery 
include an order number or details to corroborate the delivery ticket submitted. Of note, the proof of delivery is 
not itemized to indicate the specific supplies. 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 
therapeutic continuous glucose monitors/receiver (K0554) supply allowance for therapeutic continuous glucose 
monitor (CGM) (K0553) provided February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone chat with your podiatrist 
provided on May 12, 2020. 
 
You asked the Plan to waive the copayment for the specialist service. You say that the doctor did not treat you 
or prescribe medications so you should not be billed. The Plan denied your request. The Plan says you were 
charged the 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 $45 
copayment for Physician Services.  
 
You have been asked to pay a $45 copayment for the specialist service. The specialist service falls within the 
Physician 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 telephone chat 
with your podiatrist provided on May 12, 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 your care can be safely provided in a less intensive setting, such as a 
skilled nursing facility. 
 
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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, skin and O2 
care, and daily therapy can be provided at a lower level of care. You are mostly MIN/standby assist for 
functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for 
measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted. 
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 pre-approve an office evaluation, spinal manipulation, physical 
therapy exercises, massage, and electrical stimulation therapies to be provided by a chiropractor. 
 
You asked the Plan to pre-approve the chiropractic services. You say that you are having back pain and need to 
go to this provider who has treated you for 30 years. You feel that 99213 should be covered as well as the other 
requested services. The Plan denied your request. The Plan says there is no clinical evidence showing a spinal 
subluxation for which manual manipulation of the spine could be covered. The other requested services are not 
covered by Medicare when provided by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
In this case, the requested manual manipulation of the spine cannot be approved as there is no evidence of an 
examination of the back finding a subluxation. The remaining requested services are not covered if provided by 
a chiropractor. Therefore, we decided that the Plan does not have to pre-approve an office evaluation, spinal 
manipulation, physical therapy exercises, massage, and electrical stimulation therapies to be provided by a 
chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar. 
 
You asked the Plan to pre-approve a grab bar. You say that you are six feet tall and need assistance to sit and 
stand from the toilet. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar 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 grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove MyoPro Motion G Orthotic device (L8702) (Powered 
upper extremity range of motion assist device). 
 
You asked the Plan to preapprove the orthotic device. You say that the claim should be paid. The Plan denied 
your request. The Plan says your request is not medically necessary because this device has deluxe features that 
exceed your need and replaces rather than improves the function of your arm. 
 
The Plan must follow Medicare rules. Medicare rules say for a service to be considered medically necessary it 
must not be experimental or investigational. The MyoPro Motion G Orthotic device is considered experimental 
and investigational. Therefore, we decided that the Plan does not have to preapprove MyoPro Motion G 
Orthotic device (L8702) (Powered upper extremity range of motion assist device).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0837). 
 
You asked the Plan to pre-approve a power wheelchair. You say that this will help you get around easier. The 
Plan denied your request. The Plan says this is not necessary for use in your home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say that for a power wheelchair to be covered, the 
beneficiary?s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted 
cane or walker. 
 
The records show that within the home, your mobility limitation can be resolved with a walker, which the Plan 
has approved. The requested power wheelchair is shown to be for use outside the home. Although this item 
may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair (K0837).