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

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 28, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like reconsideration because 
this equipment was medically necessary. The Plan denied your request. The Plan says the submitted 
documentation does not include an itemized shipping/billing invoice or proof of delivery for the billed date of 
service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice to validate the billed 
equipment. Additionally, the delivery ticket is not for the billed date of service. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for lumbar-sacral orthosis (L0650) provided on March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids purchased on July 21, 2020. 
 
You asked the Plan to pay for the hearing aids. You say that you were not sure about the network provider. The 
Plan denied your request. The Plan says the rendering hearing aid center is not a plan provider or vendor. 
 
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 only from plan-approved vendors.  
 
We looked at the file, and the Plan's rules. The provider that you self-referred to is not a plan-approved vendor. 
Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. 
Therefore, we decided that the Plan does not have to pay for hearing aids purchased on July 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office consultation with the requested retinal 
specialist. 
 
You asked the Plan to pre-approve the office consultation with a retinal specialist. You say that this provider 
has very good reviews and is close to your home. You say that you had an authorization approved for an in-
network provider, which you rejected because you never chose to be sent there and also there were very bad 
reviews and you feel unsafe especially when it comes to treating your condition of glaucoma that has been 
going on for three years. The Plan denied your request. The Plan says a retinal specialist is not the appropriate 
specialty to treat your condition of glaucoma. 
 
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 office consultation with a retinal 
specialist. Our reviewer says that a consultation with a retinal specialist is not medically necessary. Our 
physician reviewer found your condition can be cared for by optometrist, comprehensive ophthalmologist 
and/or glaucoma specialist. There is no medically justifiable reason for you to be referred to a retinal specialist. 
There is no listed condition that would warrant a referral to a retinal specialist. There are comprehensive 
ophthalmologist and glaucoma specialist that are in-network providers that are able to treat your conditions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for an office consultation with a retinal specialist have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an office consultation with a retinal specialist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on May 15, 
2020. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that because of swelling you had to 
go back to the specialist to have the cast removed so you should not have to pay a copayment for the second 
visit. The Plan denied your request. The Plan says you have been charged this 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 $50 
copayment for Physician/Practitioner services, Specialist visit.  
 
You have been asked to pay a $50 copayment for the specialist visit. the specialist visit falls within the 
Physician/Practitioner services, Specialist visit 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 specialist visit provided on May 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis and additions (L1851, L2385 and L2397) 
provided on April 8, 2020. 
 
You asked the Plan to pay for the knee orthosis and additions. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says the documentation 
submitted does not include an itemized billing/shipping invoice or proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the 
documentation submitted does not include an itemized billing/shipping invoice to verify the supplies billed. 
Additionally, the delivery ticket included is not for the billed date of service. The record shows that the Plan 
made several attempts to obtain the necessary documentation without success. Therefore, we decided that the 
Plan does not have to pay for the knee orthosis and additions (L1851, L2385 and L2397) provided on April 8, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiovascular stress test interpretation 
provided on June 5, 2020. 
 
You asked the Plan to waive the copayment for cardiovascular stress test interpretation. You say that you 
disagree with the additional $20 charge. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct 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 $20 
copayment per visit to a specialist.  
 
You have been asked to pay a $20 copayment for cardiovascular stress test interpretation. Cardiovascular stress 
test interpretation falls within the physician/practitioner services, including doctor's office visits 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 cardiovascular stress test interpretation 
provided on June 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 
16, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the charges incurred from 
this incident are unnecessary. The Plan denied your request. The Plan says you were charged this cost sharing 
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 $260 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $215.75, which is less 
than your copayment, for these services. 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 
ambulance services provided on May 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (99601) provided on September 27, 
2019. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says CPT code 99601 is not valid for Medicare 
purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. 
Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not 
been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601) provided 
on September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation mileage incurred on May 31, 2020. 
 
You asked the Plan to pay for transportation mileage. You say that this should be covered because you had to 
travel to receive a COVID test prior to surgery. The Plan denied your request. The Plan says transportation 
costs are not covered except for services related to transplants. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of transportation mileage have not been met. Therefore, we decided that 
the Plan does not have to pay for transportation mileage incurred on May 31, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the medical records provided support the 
need for SNF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met 
and SNF care is not medically necessary. 
 
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 services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, had stable vital signs, and clear lungs. The enrollee received physical therapy, speech therapy, and 
occupational therapy in the acute hospital. The enrollee was at a contact guard level with functional mobility, 
including gait to 10 feet with a rolling walker. The enrollee required varying assist with activities of daily 
living. The enrollee tolerated a mechanical soft diet. There are no identifiable skilled nursing service needs. 
 
 
There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing 
facility setting. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for urgent care provided to the enrollee on February 15, 2020. 
 
You asked the Plan to pay for the services. You say that this claim is COVID-19-related. The Plan denied your 
request. The Plan says Medicare says non-urgent services should be from network providers who are 
contracted with the member?shealthplan and listed in the Provider Directory 
 
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 urgent care provided to the enrollee on February 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a primary care provider visit and an X-ray 
provided on March 18, 2020. 
 
You asked the Plan to waive the copayments for a primary care provider visit and an X-ray. You say that you 
disagree with the charges because you should only owe a $15 copayment for primary care provider visits. The 
Plan denied your request. The Plan says the claims were processed correctly and you are being charged the 
correct 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 $15 
copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay a 
$10 copayment for X-rays.  
 
You had a primary care provider visit on March 18, 2020. Therefore, you are responsible to pay the $15 
copayment.  
 
You had an X-ray on March 18, 2020. Therefore, you are responsible to pay the $10 copayment.  
 
The total amount you owe is: $25.  
 
You have been asked to pay the total copayment amount of $25 copayment for a primary care provider visit 
and an X-ray. A primary care provider visit falls within the physician/practitioner services, including doctor's 
 
 
office visits benefit category. An X-ray falls within the outpatient diagnostic tests and therapeutic services and 
supplies 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 a primary care provider 
visit and an X-ray provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames and lenses (V2020 and V2200) provided by on out-
of-network provider on May 18, 2020 
 
You asked the Plan to pay for the frames and lenses. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says benefits received at a non-network optical 
provider are excluded. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers $200 toward the purchase and fitting of eyeglasses and pair of lenses or contact 
 
 
lenses at a network optical provider (1 per calendar year).  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the frames and lenses have not been met. Specifically, the record does not indicate that you 
received the frames and lenses from a network optical provider. Therefore, we decided that the Plan does not 
have to pay for frames and lenses (V2020 and V2200) provided by on out-of-network provider on May 18, 
2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit and debridement of nails services 
provided on June 4, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the rest home visit and debridement of nails services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are 
not a covered benefit. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the rest home visit and debridement of nails 
services provided on June 4, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee. 
 
You asked the Plan to pre-approve the spacer. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service 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 spacer. Our reviewer says that the 
requested spacer is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer remains 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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Superion interspinous spacer for the enrollee.
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 enrollee has failed management at a 
lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the 
current acute care facility. 
 
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 physician 
reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical 
services that are materially different than those of short term acute care hospitals. In this case, ongoing care 
needs include respiratory support with ventilator management and tracheostomy care, intravenous antibiotics, 
surveillance laboratory studies, tube feedings, and therapy services. The documentation does not support that 
the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where 
he is currently receiving care. There are no required medical services identified that are available at the 
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee at this time. 
 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services provided from April 6, 
2020 to April 12, 2020. 
 
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
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 99232 is subsequent hospital care, per day, for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded 
problem focused interval history; An expanded problem focused examination; Medical decision making of 
moderate 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 patient is responding inadequately to therapy or has developed a minor 
complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
We find that CPT code 99232 is not supported in the medical record. Specifically, these services were reported 
twice by physicians of the same specialty on the same dates. Based on this information, we decided that 
Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided 
that the Plan does not have to pay for the subsequent hospital care services provided from April 6, 2020 to 
April 12, 2020.