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

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair and accessories. 
 
You asked the Plan to pre-approve a replacement power wheelchair and accessories. You say that the enrollee 
needs a new power wheelchair for proper support. The Plan denied your request. The Plan says the enrollee's 
current power wheelchair seat cushions can be replaced for support. 
 
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 a replacement power wheelchair and 
accessories. Our reviewer says that the replacement power wheelchair is not medically necessary. Our 
physician reviewer found the documentation does reveal that the enrollee has a personal mobility deficit but the 
documentation does not reveal that this deficit currently impairs participation in MRADLs in the home. The 
enrollee's mobility deficit is presently helped by the currently owned power wheelchair. The documentation 
 
 
reveals the enrollee has the cognition and vision to safely operate a PMD but the documentation does not 
indicate that the enrollee requires a replacement power wheelchair. The face to face physician visit does not 
indicate that there is irreparable wear to the enrollee's current wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a replacement power wheelchair and accessories have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a replacement power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided. 
 
You asked the Plan to pay for the endodontic therapy. You say that you had throbbing pain and required a root 
canal. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. 
 
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. Therefore, we decided that the Plan does not have to pay for the 
endodontic therapy (D3320) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid services received on June 19, 2020. 
 
You asked the Plan to pay for the services. You say that you contacted the provider and are not being told that 
the service is not covered. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids up to $1000 per hearing aid, per ear, every three years. 
 
The file shows that the full benefit for hearing aids was already paid for by the plan on this claim. You are 
responsible for the remaining balance of $950. Based on this information, we decided that the Plan's rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aid services received on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services provided to the enrollee
 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that prior authorization was not obtained. 
 
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 ophthalmological services provided to the 
enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says screening tests are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, A1c testing, was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on June 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3D rendering for magnetic resonance imaging (MRI). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has an elevated prostate 
specific antigen (PSA) level and has declined prostate biopsy. The documentation does not support that 3D 
rendering of a pelvic MRI is reasonable and medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 3D rendering for magnetic resonance imaging (MRI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup provided. 
 
You asked the Plan to pay for the core buildup. You say that you want your $250 dental allowance that you 
receive yearly. The Plan denied your request. The Plan says you have exceeded your annual maximum. 
 
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, you also have an annual allowance of 
$250. The Plan paid $250 toward the dental services received, which exhausted your 
benefit. Therefore, we decided that the Plan does not have to pay for core buildup provided.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for diagnostic testing provided by a 
participating provider on July 2, 2020. 
 
You asked the Plan to waive the copayment for diagnostic testing. You say that you were told that these tests 
would be covered with your annual wellness exam. The Plan denied your request. The Plan says the correct 
copayment has been 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 $10 
copayment for outpatient diagnostic tests/other diagnostic tests.  
 
You have been asked to pay a $10 copayment for diagnostic testing. Services were provided that beyond an 
annual wellness exam; therefore, the correct copayment has been applied. Diagnostic testing falls within the 
outpatient diagnostic tests/other diagnostic tests 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 diagnostic testing provided by a participating provider on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 27, 
2020, to February 28, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says 
care could have been provided at the observation level. 
 
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 the 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 that the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or 
observation 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 the 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 from February 27, 2020, to 
February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services received on June 16, 2020. 
 
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 the claim was processed appropriately. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $500 deductible for covered medical services.  
 
The item or service you asked the Plan to pay for falls within the benefit category covered medical services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for 
covered medical services. This cost sharing is a contractual obligation that had not been met at the time the 
services was received on June 16, 2020. Therefore, we decided that the Plan does not have to pay for laboratory 
services received on June 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea MyoPro orthotic device.You asked the Plan to pre-approvethe requested device. You say that traditional rehab, and less sophisticated devices have been tried and failed.The Plan denied your request. The Plan says there is insufficient evidence of the device's effectiveness.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 requested device. Our physician reviewer found that the enrollee has a history of a left basal ganglia stroke with right side hemiparesis. There is no documentation that the requested device is medically reasonable and necessary to treat the enrollee's condition. The device is considered experimental and investigational for the enrollee's diagnosis.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 requested device have not been met.Therefore, we decided that the Plan does not have to pre-approvea MyoPro orthotic device.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit on May 31, 
2020. 
 
You asked the Plan to waive the copayment for the emergency department visit. You say that you pay enough 
for the coverage that you should not have to pay for anything else. 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 $110 
copayment for Emergency Care.  
 
You have been asked to pay a $110 copayment for the emergency department visit. the emergency department 
visit falls 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 copayment for 
the emergency department visit on May 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676). 
 
You asked the Plan to pay for a pneumatic compression device. You say that you required the device. The Plan 
denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent 
deep vein thrombosis during and/or following surgery. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism is a preventive service. PCDs billed by E0675 are not 
covered. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided 
that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 13, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 February 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiology services provided by a 
participating provider on December 9, 2019. 
 
You asked the Plan to waive the coinsurance for a fluoroscopy. You say that you should only be charged for an 
outpatient surgery. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% 
coinsurance for outpatient diagnostic tests/radiological diagnostic service.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a fluoroscopy. The total allowed 
amount is $7,905.62. The total amount you are being asked to pay is $1,581.12 ($7,905.62 x 20% = $1,581.12) . 
A fluoroscopy falls within the outpatient diagnostic tests/radiological diagnostic service 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 coinsurance for radiology services provided by a participating provider on 
December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient psychiatric services provided from April 6, 2020, through April 15, 2020.You asked the Plan to pay forthese services. You say that the inpatient psychiatric services provided were medically necessary for the enrollee.The Plan denied your request. The Plan says the inpatient psychiatric services provided were not medically necessary. Treatment for the member could have been provided at a less intensive level of care, such as observation.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the inpatient psychiatric services provided were not medically necessary. Our physician reviewer found that the patient was admitted to the acute inpatient psychiatric hospitalization on April 6, 2020 with Schizoaffective Disorder Bipolar Type. Based upon review of the records provided it was not expected this enrollee would improve in a reasonable period of time as he had passive dangerousness to self with no plan and no homicidal thoughts. The patient did not have any auditory or visual hallucinations, or delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did have passive dangerousness to self but no homicidal thoughts, perceptual disturbance including auditory or visual hallucinations. The Plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that theservices were reasonably expected to improve the patient's condition or were for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated bya physician. Based upon the review of the records provided, the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient had passive dangerousness to himself with no plan but no homicidal thoughts, agitation or aggression without perceptual disturbance including auditory or visual hallucinations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these serviceshave not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient psychiatric services provided from April 6, 2020, through April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2385, L2397) provided. 
 
You asked the Plan to pay for orthotics. You say that these items were medically necessary. The Plan denied 
your request. The Plan says there is no evidence of an established relationship between the member and the 
ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
 
 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for orthotics (L1851, L2385, 
L2397) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wig (A9282) purchased on June 5, 2020.You asked the Plan to pay fora wig. You say that this is necessary due to the hair loss caused by chemotherapy.The Plan denied your request. The Plan says this is not covered.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to pay fora wig (A9282) purchased on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a seat lift chair with upgraded covering/fabric. 
 
You asked the Plan to pay for the chair. You say that this is necessary due to a right shoulder replacement. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. 
 
You have arthritis of the right shoulder. This is covered for severe arthritis of the hip or knee, or neuromuscular 
disease. As the chair itself is not coverable, the upgrade cannot be covered either. Based on this information, 
we decided that Medicare rules for coverage of the chair have not been met. Therefore, we decided that the 
Plan does not have to pay for a seat lift chair with upgraded covering/fabric.