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

We decided that the Plan does not have to pay for gym benefits from January 1, 2019, through December 1, 
2019. 
 
You asked the Plan to pay for gym benefits from June 1, 2019, through December 1, 2019. You say that the 
Plan should pay for this gym membership. The Plan denied your request. The Plan says it was confirmed that 
there are gyms that participate in the Renew Active within 20 miles of your address. Because you purchased a 
membership at a gym that was not a part of Renew Active, the claim was denied correctly. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits 
only when participating facilities. The Plan's rules for coverage of gym benefits have not been met because you 
used a provider who is not participating with the Renew Active Fitness program. Therefore, we decided that the 
Plan does not have to pay for gym benefits from January 1, 2019, through December 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (G0483) provided May 14, 2020. 
 
You asked the Plan to pay for laboratory services. You say that you would like reconsideration based on the 
records provided. The Plan denied your request. The Plan says the billed services are not supported. 
 
The Plan must follow Medicare rules. The rules say for Medicare to consider coverage and payment for any 
item or service, the information submitted by the supplier or provider must corroborate the documentation in 
the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record did not contain medical records 
from the ordering physician. The lab order within the record was signed after the date of service at issue. The 
billed services are not corroborated by medical records or a valid physician order. Therefore, we decided that 
the Plan does not have to pay for laboratory services (G0483) provided May 14, 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 would like reconsideration because 
admission to the LTACH is medically necessary for stabilization and to prepare the enrollee for the next 
appropriate level of care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH 
care have not been met. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the member requires that are not already 
available and covered at the current facility. 
 
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the home health services. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says the requested 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that you do not have documented skilled nursing needs. There is no evidence of new or changing needs. 
Our physician reviewer found the requested home health skilled nursing services are not medically necessary or 
reasonable. 

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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 5, 2019 and 
billed under code G0483. 
 
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 the documentation submitted did not include a physician order/lab requisition or medical 
records stating exactly what tests are to be performed. The submitted Laboratory Requisition indicates that 
23490 UDS Drug Abuse Panel was requested.  The submitted documentation does not itemize what tests are 
included in this panel; therefore, the billed code 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 and when necessary provide specific information 
regarding the testing ordered. In this case, the records provided do not support the services billed. Therefore, 
we decided that the Plan does not have to pay for lab services provided to the enrollee on July 5, 2019 and 
billed under code G0483.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller (E2377), expandable harness 
(E2313) and electronics (E2311) and replacement cushion cover (K0108). 
 
You asked the Plan to pre-approve the items. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the items have not been met. E2377 Expandable Controller, E2313 
Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are 
requested to control power tilt, recline and power elevating leg rests through the joystick. The notes state that 
these are needed when 3 or more actuators are being used. The electrical connection between the wheelchair 
controller and two or more motors (E2311), expandable controller (E2377) and harness (E2313) cannot be 
covered. Although there are three approved power options on this wheelchair (tilt, recline and elevating leg 
rests), there is not a medical need to control these power options through the joystick Physician's exam from 
September 2, 2020, shows that member has normal left upper limb strength. Member is independent with 
dressing, grooming and feeding with set up. This upper limb strength and function are adequate for the member 
to be able to control the power options using their own switches which are included in the allowance of these 
power options. 
 
There is a request for K0108 liner polyurethane curved. This is a seat cover and is properly coded E2619 
Replacement cover for wheelchair seat cushion or back cushion, each. A replacement cover cannot be covered 
with initial issue. The approved E2607 Seat Cushion already comes with a cover. Therefore, we decided that 
the Plan does not have to pre-approve expandable controller (E2377), expandable harness (E2313) and 
electronics (E2311) and replacement cushion cover (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on 
December 10, 2019. 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 10, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit (99285) provided on February 13, 2020. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration 
because payment for this service was down-coded inappropriately. The Plan denied your request. The Plan says 
that the evaluation and management services were paid for at a lower level because the documentation 
submitted did not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 
3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or 
mental status: A comprehensive history; A comprehensive examination; and 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 high severity and pose an immediate significant threat 
to life or physiologic function.  
 
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 emergency department visit. Our 
reviewer says that CPT code 99285 meets criteria for billing and reimbursement consideration. Our physician 
reviewer found research on what is required for CPT code in question shows that the documentation supports 
this code. 
 
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 emergency department visit have been met. Therefore, we decided that the 
Plan has to pay for the emergency department visit (99285) provided on February 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the 20% coinsurance for an injection provided out of network 
on June 2, 2020.  
 
You asked the Plan to the cost of this injection. You say that you were told this treatment would be covered. 
The Plan says they are partially reducing the cost-share by waiving the administration or infusion fee. The Plan 
states that the 20% coinsurance was applied correctly per the enrollee's 2020 plan benefit package. 
 
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 20% 
coinsurance for Medicare Part B drugs. 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 administration fee and 20% coinsurance for an 
injection provided out of network on June 2, 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 the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Therefore, this request for LTACH services will be considered not 
medically necessary. Transfer to a lower level of care may be considered when the treatment has completed and 
long-term respiratory status is more clear. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove intermittent limb compression device. 
 
You asked the Plan to preapprove intermittent limb compression device. You say that the claim should be paid. 
The Plan denied your request. The Plan says the information must include the response to an initial treatment 
with the device. The clinical response includes the change in measurements before and after treatment. 
 
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically 
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with 
venous stasis ulcers. There must be a trial of the equipment demonstrating effectiveness.  
 
The file does not show that the enrollee has had the trial of the equipment that Medicare requires. Therefore, 
we decided that the Plan does not have to preapprove intermittent limb compression device.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 200mg Vimpat Tablets. 
 
You asked the Plan to pre-approve the Vimpat. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the member's 
condition under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve 200mg Vimpat Tablets.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $40 copayment for a diagnostic mammogram provided on 
July 29, 2020. 
 
You asked the Plan to waive this copayment. You say that this copayment is not correct. The Plan denied your 
request. The Plan says this was ordered as a diagnostic mammogram which has a copayment. 
 
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 outpatient diagnostic services. 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 $40 copayment for a diagnostic 
mammogram provided on July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311). 
 
You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your 
request. The Plan says the items are not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
There is a request for a K0108 Wheel Accent Color. This does not serve a medical purpose. 
It is not covered as it is not reasonable and necessary per Medicare criteria. E2311 Electro Connect Btw 2 Sys 
Electro Connect Btw 2 Sys is requested to control power tilt and power elevating leg rests through the joystick. 
The notes state that these are needed when 2 or more actuators are being used. The electrical connection 
between the wheelchair controller and two or more motors (E2311) cannot be covered. Although there are two 
approved power options on this wheelchair (tilt and elevating leg rests), there is not a medical need to control 
these power options through the joystick. The item at issue in this appeal does not serve a purpose that is 
primarily medical in nature. This item is available to the general public and would be helpful even to those who 
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve Wheel Accent Color 
(CPT Code K0108) and power wheelchair accessory, electronic connection between 
wheelchair controller and two or more power seating system motors, including all related electronics, indicator 
feature, mechanical function selection switch, and fixed mounting hardware (E2311).
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 the records provided support the need for IRF care. 
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The 
Plan says that the enrollee's care can be safely provided in a less intensive setting. 
 
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 that there are no identified problems that need inpatient medical management and 
there are no complex nursing or rehabilitation needs. Our reviewer says that the medical records do not support 
a need for an intensive rehabilitation therapy program. 
 
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
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 Procrit. Our reviewer says that the 
documentation does not support that the enrollee has tried and failed the Plan's required drugs. Our physician 
reviewer found there is no expectation that the preferred Retacrit would be less effective or have more side 
effects as all available Epoetin Alfa products such as Procrit and Retacrit have been shown in current literature 
to have essentially equal benefit and risk. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve the 9 skilled nursing visits. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says the additional 
skilled nursing services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 9 skilled nursing visits. Our 
reviewer says that you do not have documented skilled nursing needs. Our physician reviewer found 
phlebotomy services alone are not an indication or skilled nursing visits. 
 
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 9 skilled nursing visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 9 additional home health skilled nursing visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require these stockings but no 
longer are able to afford them. The Plan denied your request. The Plan says the compression stockings are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.