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

We decided that the Plan does not have to pre-approve a group 2 multiple power option Power Wheelchair with
accessories (K0841, E1010, E2361, E2605)
You asked the Plan to pre-approve the power wheelchair and accessories. You say that the chair and
accessories are medically necessary. The Plan denied your request. The Plan says the requested chair and
options exceed the enrollee's needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 power wheelchair and accessories.
Our reviewer says that the group 2 power wheelchair with multiple power options is not medically necessary.
Our physician reviewer found the progress notes indicate the enrollee is ambulatory without restrictions. He
has no weakness. He has no difficulty walking, climbing stairs, dressing, bathing, doing errands alone. He is
noted able to care for himself. The documentation is conflicting on whether the enrollee's mobility deficit could
be helped by the use of a walker, cane, or manual wheelchair. The request for the power tilt/recline feature does
not meet medical necessity.
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 power wheelchair and accessories have not been met. Therefore, we decided
that the Plan does not have to pre-approve a group 2 multiple power option Power Wheelchair with accessories
(K0841, E1010, E2361, E2605)
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac device remote monitoring provided on December 15, 
2019. 
 
You asked the Plan to pay for the cardiac device remote monitoring. 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 cardiac device remote monitoring provided on December 15, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker with trunk support. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has a cane that is functioning similarly. 
 
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 you do not meet Medicare coverage criteria for the requested walker as you are functional with a cane at 
home with no problems. The requested walker is not medically necessary. The documentation does not support 
the need for the requested walker since you have a cane that is functioning well at home similarly. 
 
 
 
 
 
 
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 a walker with trunk support.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided from February 11, 2020 
to February 14, 2020. 
 
You asked the Plan to pay for the home health aide services. You say that none of the providers on the Plan's 
approved list were able to provide services in Kent, Ohio. The Plan denied your request. The Plan says the 
member must receive their care from a network provider. In most cases, care receive from an out-of-network 
provider will not be covered. 
 
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 home health aide services provided from February 11, 2020 to 
February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.
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 laboratory services provided to the enrollee on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on February 18, 2020.

You asked the Plan to pay for the nurse practitioner 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 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 nurse practitioner services provided on February 18, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital physician visit provided on November 16, 2019. 
 
You asked the Plan to pay for physician visit. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was 
enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment of 
this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a hospital physician visit provided on November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided on
February 24, 2020.
You asked the Plan to pay for neuromuscular junction testing. You say that this is documented in the records.
The Plan denied your request. The Plan says this code is not appropriate for train of four testing.
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 95937 is neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method.
We find that CPT code 95937 is not supported in the medical record. Specifically, the use this code to report
train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately
reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this
information, we decided that Medicare rules for coverage of neuromuscular junction testing have not been met.
Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) provided
on February 24, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room visits provided on April 
20, 2020 and May 27, 2020. 
 
You asked the Plan to waive the copayments for emergency room visits. You say that the provider did not do 
anything to help you at either visit. The Plan denied your request. The Plan says the copayment amounts you 
are being charged are 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 $90 
copayment for each emergency room visit. There were 2 visits, resulting in a total copayment obligation of 
$180. 
 
You have been asked to pay $90 copayment for each emergency room visit. Emergency room visits fall 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 copayments for emergency room 
visits provided on April 20, 2020 and May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on January 15, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nursing facility discharge services provided on January 6, 
2020. 
 
You asked the Plan to pay for the nursing facility discharge services. The Plan denied your request. The Plan 
says services from non-participating providers are not covered under open access unless pre-authorized. 
 
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 nursing facility discharge services provided on January 6, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for Orthoptic and/or pleoptic training provided on February 14, 2020.
You asked the Plan to pay for the optic training. You say that you were referred to have these services provided due to vision issues after your stroke and feel they should be covered. The Plan denied your request. The Plan says that these services are excluded from coverage under your contract.
Please note, the coverage exclusion cited by the Plan in your EOC only applies to coverage under your supplemental vision benefit. These services are described by code 92065 which is an active code in the Medicare Physician Fee Schedule. This means that this code can be covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided with the optic training by a contract provider. The file does not show that the Plan provided notice that the optic training would not be covered. Under Medicare rules, this means the optic training is considered approved by the Plan. Therefore, we decided that the Plan has to pay for Orthoptic and/or pleoptic training provided on February 14, 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on February 22, 
2020. 
 
You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documents received do not support CPT 
code 93010 as being rendered as an interpretation and report by the billing provider was not included. 
 
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 93010 is electrocardiogram, routine ECG with at least 12 
leads; interpretation and report only.  
 
We asked our coder 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 electrocardiogram. Our reviewer says that CPT code 
93010 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation 
did not include an interpretation and report prepared by the provider. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan 
does not have to pay for an electrocardiogram (93010) provided on February 22, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pay for endoscopy services (43239) provided on October 30, 2019. 
 
You asked the Plan to pay for the endoscopy services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that payment for the procedure with the 
highest allowance was made under CPT code 43259. 
 
The Plan must follow Medicare rules. Medicare rules say that if Field 21 contains an indicator of ?3,? pay the 
full value of the highest valued endoscopy, plus the difference between the next highest and the base 
endoscopy. 
 
We find that CPT code 43239 is supported in the record. Specifically, there is no evidence that the full value of 
the highest value endoscopy plus the difference between the next highest and base endoscopy has been paid. 
Based on this information, we decided that Medicare rules for coverage of the endoscopy services have been 
met. Therefore, we decided that the Plan has to pay for endoscopy services (43239) provided on October 30, 
2019.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at a skilled nursing facility from 
March 17 to March 20, 2020. 
 
You asked the Plan to waive the copayment for a stay at a skilled nursing facility. You say that the first 20 days 
of a stay at a skilled nursing facility have a $0 copayment. The Plan denied your request. The Plan says the 
correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160 
copayment for each day for days 21 to 62 of a stay at a skilled nursing facility.  
 
You have been asked to pay a $160 copayment per day for a 3-day stay at a skilled nursing facility. The case 
record documents that you previously spent 20 days in February 2020 in a skilled nursing facility within the 
same benefit period. 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 stay at a skilled nursing facility 
from March 17 to March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on 
February 11, 2020. 
 
You asked the Plan to pay for the scaling and planing. You say that you were given approval to receive a 
periodontal scaling and root planing of the upper right quadrant. You also say that the provider told you the rest 
would of the charge would be covered because it was approved by the Plan. The Plan denied your request. The 
Plan says the Plan says that this service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. The records show that the approval letter for this service states you 
must be enrolled with the Plan at the time of service(s). The authorization will not apply if you end your 
coverage. The records show that you did not opt to purchase the optional supplemental dental plan for 
comprehensive coverage. Therefore, we decided that the Plan does not have to pay for the periodontal scaling 
and root planing provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient hospital services provided April 14, 2020. 
 
You asked the Plan to pay for the outpatient services. You say that you are requesting reconsideration as these 
services were deemed appropriate and medically necessary for the enrollee. Please review attached medical 
records to support the pertinent services rendered. The Plan denied your request. The Plan says  because the 
enrollee was admitted to the facility on 4/17/2020, these services were included on the inpatient claim dated 
4/14/2020 - 04/21/2020 under another claim number. 
 
The Plan must follow Medicare rules. Medicare rules say that pre-admission services provided by the admitting 
hospital, or by another entity under arrangements with the admitting hospital, within 3 days prior to and 
including the date of the admission are deemed to be inpatient services and included in the inpatient payment. 
 
In this case, the CPT Code Manual definition of codes  (36415) collection of venous blood by venipuncture 
(80048) basic metabolic panel (Q4121) Theraskin (15275) skin substitute graft.  We find that these services are 
included on the inpatient claim dated April 14, 2020 - April 21, 2020 under another claim number as the 
enrollee was admitted to the facility as an inpatient on April 17, 2020. Based on this information, we decided 
that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the 
Plan does not have to pay for the outpatient hospital services provided April 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 6, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for laboratory testing. You say that you are appealing. The Plan denied your request. 
The Plan says the denial of payment for these services is correct, because this provider is out-of-network with 
the Plan and the referring physician is also out-of-network with 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 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 medical services provided on February 6, 2020 
by an out of network (OON) provider.