Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network wellness center. 
 
You asked the Plan to pre-approve the referral. You say that your request is absolutely medically necessary for 
sleep deprivation. The Plan denied your request. The Plan says there are in-network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
a referral to an out-of-network wellness center.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care received on June 3, 2020. 
 
You asked the Plan to pay for the services. You say that you attempted to stay in-network for this service. The 
Plan denied your request. The Plan says the claim processed correctly as billed. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and 
eyewear.  
 
The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we 
decided that the Plan does not have to pay for vision care received on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the x-ray of the spine and pelvis you had on 
June 3, 2020, at an outpatient hospital facility. 
 
You asked the Plan to waive the copayment for the x-ray. You say that your share of the cost should not be this 
high. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan also 
said that because the allowed amount for this service is less than your copayment obligation, you are 
responsible for the full 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 $110 
copayment for basic radiological services at an outpatient hospital facility.  
 
You have been asked to pay a $110 copayment for the x-ray. The x-ray falls within the basic radiological 
services at an outpatient hospital facility 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. 
 
Please note that this decision only applies to the x-ray services, not the CT scan you reference in your appeal. 
Therefore, we decided that the Plan does not have to waive the copayment for the x-ray of the spine and pelvis 
you had on June 3, 2020, at an outpatient hospital facility.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for air ambulance services (A0431, A0436) provided April 9, 2020. 
 
You asked the Plan to pay for the air ambulance services. You say that the service was medically necessary. 
The Plan denied your request. The Plan says that coverage criteria was not met. 
 
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 air transport was medically necessary. Our physician reviewer found the enrollee was sufficiently 
acutely ill that permanent injury from metabolic symptoms were possible with delay in care. Air ambulance 
transport was medically indicated. 
 
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 
has to pay for air ambulance services (A0431, A0436) provided April 9, 2020.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necesasry. The Plan denied your 
request. The Plan says this is considered experimental and investigational. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on March 9, 2020 and 
billed under codes 80157, 80177, 80201, 80162, 80159, and 80173. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met. The Plan says that while codes G0483 and 81037 
were paid, the remaining codes were denied because the documentation submitted did not support that this 
testing was performed with blood sampling. Blood specimen collection is by venipuncture; however, the lab 
requisition states a urine specimen was collected; therefore, the billed service cannot be verified. It is noted 
multiple attempts were made to obtain additional information from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case, this claim cannot be paid due to the type 
of specimen that was reported to have been tested (blood versus urine). Medicare billing criteria are not met.  
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 9, 
2020 and billed under codes 80157, 80177, 80201, 80162, 80159, and 80173.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a CPAP device. 
 
You asked the Plan to pre-approve the backup. You say that this is needed especially during hurricane season. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
A backup battery is not a covered benefit. It is duplicative. Therefore, we decided that the Plan does not have to 
pre-approve a backup battery for a CPAP device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you feel that the enrollee would benefit from and can 
tolerate an intensive interdisciplinary treatment program of 3 hours of therapy per day 5 days per week under 
the supervision of a physician. The Plan denied your request. The Plan says the enrollee does not need to be 
seen by a rehab doctor 3 times a week, and does not need an intensive team for their care. 
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does 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. Our physician reviewer also found that there is not a reasonable expectation 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 acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 9, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 9, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture. 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that you cannot afford a new 
denture. The Plan denied your request. The Plan says the annual maximum coverage amount has been reached. 
 
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 offers a maximum plan 
benefit coverage amount of $750 per year. You are responsible for any cost above the $750 maximum. The 
record shows that you were approved for partial payment of a complete maxillary denture, which met the 
annual maximum benefit on September 1, 2019, and your annual maximum benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments charged for physician services, diagnostic 
services and Medicare Part B drugs provided from September 15, 2018 to December 3, 2019. 
 
You asked the Plan to waive this cost share. You say that you do not believe this cost share is correct. The Plan 
denied your request. The Plan says review of the claims in question shows you are only being charged your 
contractual copayment for each service provided.  
 
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 cost 
share for Medicare Part B drugs, outpatient diagnostic services and physician services. We review the claims 
submitted by the Plan. Based on this review, we find the cost share charged in each instance was based on the 
services provided and the copayment or coinsurance required based on your Plan contract agreement for 2018 
and 2019. You have been asked to pay the correct amount based on your 2018 and 2019 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 copayments charged for physician services, diagnostic services 
and Medicare Part B drugs provided from September 15, 2018 to December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 21, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on May 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SNF admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is not capable of taking care 
of the infected area. You also say that the enrollee is unable to do daily activities in a home setting. The Plan 
denied your request. The Plan says the specialized skill, knowledge, and judgement of a skilled professional 
nurse is not required to provide medically necessary and reasonable treatment safely and effectively. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy 
needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for 
coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-
approve a SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share charged for physician services provided from 
March 26, 2018 to December 20, 2019. 
 
You asked the Plan to waive the cost share for physician services and durable medical equipment provided to 
you from March 26, 2018 to December 20, 2019. You say that your providers are sending you bills, and you 
believe they are incorrect. The Plan denied your request. The Plan says the balances you are being billed are 
your cost share for each service provided during the 2018 and 2019 contract year. 
 
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 
coinsurance or cost share for physician serviced, diagnostic testing and Medicare covered durable medical 
equipment. We reviewed the Explanation of Benefits submitted for claims in question from March 2018 to 
December 2019. We find the Plan covered the services provided, minus your contractual copayment for each 
service or durable medical equipment provided. 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 cost share charged for services and 
durable medical equipment provided from March 26, 2018 to December 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested provider. 
 
You asked the Plan to pre-approve the physical therapy services. You say that you have been to several other 
physical therapy groups and you feel that you have made a great deal of progress with this provider. The Plan 
denied your request. The Plan says you must receive care from in-network providers with the exception of 
emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be 
provided with an in-network provider, which requires prior authorization from the plan.  
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure, unlisted procedure, spine 
(22899). 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided should support 
the necessity of the service in dispute. The Plan denied your request. The Plan says Intracept procedure is 
considered experimental and investigational and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the intracept procedure, unlisted procedure, spine (22899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services provided as part of a clinical trial. 
 
You asked the Plan to pre-approve services provided as part of a clinical trial. You say that you would like the 
Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve services provided as part of a clinical trial. The Plan does not 
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have 
to pre-approve services provided as part of a clinical trial.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 

You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this device would improve your 
quality of life. The Plan denied your request. The Plan says the criteria for coverage of this device have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered by 
Medicare when the beneficiary is insulin-treated with three or more daily injections of insulin. 
 
We looked at the file and Medicare rules. The submitted medical records do not show that you are insulin-
treated with three or more daily injections of insulin. Based on this information, we decided that Medicare rules 
for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 4, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 4, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 4, 2020.