Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visits (99335, 99326) provided on June 26, 2019 to November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON domiciliary or rest home visits. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not 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 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 domiciliary or rest home visits (99335, 99326) provided on June 26, 2019 to November 13, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that you did not know the ambulance was out of network and was not asked about transportation. They just told you that you were going to a more equipped hospital because of your condition. 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 $300 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $300 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection (E2311) expandable controller (E2377) and expandable controller harness (E2313).
You asked the Plan to pre-approve the upgraded electronics. You say that the requested accessories are essential in preserving the enrollee's health and independence while reducing her need for caregiver assistance. The Plan denied your request. The Plan says these items cannot be covered as it is not medically necessary to control the three approved power options through the joystick.
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 upgraded electronics. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested items are not medically necessary and not approved over standard wheelchair accessories.
These items will not allow for/are not needed for the power wheelchair to function. As such, these requests are not medically necessary. 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 upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection (E2311) expandable controller (E2377) and expandable controller harness (E2313).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee benefits from PT to assure appropriate range of motion. The Plan denied your request. The Plan says the enrollee does not require input from a skilled therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional services. Our physician reviewer found that the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has shown no improvement in knee range of motion from prior therapy. She was educated on skin breakdown, contracture prevention and splint wearing. The enrollee's needs do not require ongoing skilled therapy services. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prodigy autocode meter kit.
You asked the Plan to pre-approve a prodigy autocode meter kit. You say that the items are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
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 a prodigy autocode meter kit. Our
reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no reason given why the enrollee could not use accuchek or truemetrix
meters. The Prodigy meter is a talking meter and it is typically used in enrollees who cannot see the screen on
other hand held meters. Since we are not given any reason why the prodigy is needed in this case, we cannot
say it is medically justified per plan language which prefers other meters.
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 prodigy autocode meter kit have not been met. Therefore, we decided that the
Plan does not have to pre-approve a prodigy autocode meter kit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional service of preparation and provision of
antigens for allergen immunotherapy provided by an out of network provider on December 16, 2019.
You asked the Plan to pay for the professional service of preparation and provision of antigens for allergen
immunotherapy. You say that you needed the allergy serum. The Plan denied your request. The Plan says you
did not get 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 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 professional service of preparation and
provision of antigens for allergen immunotherapy provided by an out of network provider on December 16,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-strength lightweight wheelchair and a semielectric
hospital bed for the enrollee.
You asked the Plan to pre-approve the items. You say that the enrollee will significantly benefit from these
items. The Plan denied your request. The Plan says this request is not medically necessary at this time.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND
3. Requires frequent changes in body position and/or has an immediate need for a change in body position.
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 items. Our reviewer says that the
requested items are not medically reasonable or necessary. Our physician reviewer found there is no
documentation that the enrollee's condition requires positioning of the body in ways that are not feasible in an
ordinary bed. There is no documentation that the enrollee requires frequent changes in body position, or a need
for immediate changes in body position. There is no documentation that enrollee's condition requires special
attachments that cannot be fixed and used on an ordinary bed. In terms of the wheelchair, the enrollee meets
neither the standard criteria for a manual wheelchair, nor the specialized specific criteria for the high strength
and lightweight 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 the items have not been met. Therefore, we decided that the Plan does not have
to pre-approve a high-strength lightweight wheelchair and a semi-electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and bitewing x-rays (D0274)
provided on January 23, 2020.
You asked the Plan to pay for the dental services. You say that you were never advised that you had an
assigned dentist. You also say you were not advised that you needed to do anything differently. The Plan
denied your request. The Plan says the provider in this case is not network provider. The Plan says that dental
services must be provided by your assigned dental provider in order to be covered. The Plan also says that a
welcome letter, including an ID card, was sent to you on August 21, 2019.
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 and prophylaxis and bitewing x-rays
are listed as covered services, you must receive these services from your assigned dental provider in order for
them to be covered. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and
bitewing x-rays (D0274) provided on January 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tamsulosin HCl 0.4mg capsule (J8499).
You asked the Plan to pre-approve Tamsulosin HCl 0.4mg capsule. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not
include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been
met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tamsulosin HCl 0.4mg
capsule (J8499).
Benefits for Tamsulosin HCl 0.4mg capsule may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation to medical appointments.
You asked the Plan to pre-approve the non-emergency transportation. You say that the enrollee claims she is
not able to get to appointments using public transit due to her disabilities. The Plan denied your request. The
Plan says there is no indication that ambulance transportation is necessary for your medical condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination. Nonambulance
transportation is also not covered by Medicare. Therefore, we decided that the Plan does not have to
pre-approve non-emergency transportation to medical appointments.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for Home Health services provided on October 12, 2019 through
December 10, 2019.
You asked the Plan to pay for the Home Health services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the "from" date submitted on the RAP
does not match the "from" date on the final claim.
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required. Any claim
with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Home Health services have been met. Specifically, this claim has been billed correctly per
Medicare guidance. Therefore, we decided that the Plan has to pay for Home Health services provided on
October 12, 2019 through December 10, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services on August 15, 2019.
You asked the Plan to pay for ambulance services. You say that the claim should be paid. The Plan denied your
request. The Plan says while enrolled under the Medicare hospice benefit, Original Medicare is responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition.
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 dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for ambulance services on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous vain medication and supplies.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says no information was provided as to why the enrollee is on long-term Milrinone.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 medically reasonable or necessary. Our physician reviewer found Milrinone has not
been found to be safe and effective in the long-term (beyond 48 hours) treatment of heart failure, whether
administered orally (an oral dosage form of milrinone currently is not available in the US) or by continuous or
intermittent IV infusion. The records do not indicate class of congestive heart failure and the use is not
consistent with compendia recommendations. Medical necessity is not determined.
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 continuous vain medication and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on February 4, 2019 to February
27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the referring provider is also out-of-network.
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 physical therapy provided on February 4, 2019 to
February 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 30, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were unaware you needed prior authorization
from the member's primary care physician (PCP) to continue these services. The Plan denied your request. The
Plan says no prior authorization was obtained. The plan says that the member's PCP did not refer these
services.
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 an office visit provided on October 30, 2019 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a FreeStyle Libre Continuous Glucose Monitoring System.
You asked the Plan to provide a continuous glucose monitor. You say that the Plan changed your machine and
doesn't want to cover your reader. The Plan denied your request. The Plan says criteria for a CGM is not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked the file and Medicare rules. The record shows you are not insulin injecting three or more times a
day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor
have not been met. Therefore, we decided that the Plan does not have to provide a FreeStyle Libre Continuous
Glucose Monitoring System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on March 5, 2019 to March 27,
2019 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that the referring provider is also out-of-network.
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 physical therapy provided on March 5, 2019 to
March 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits, the surgical
supplies, and the ultrasounds provided on February 7, 2019 and April 1, 2019.
You asked the Plan to waive the cost share for the specialist office visits, the surgical supplies, and the
ultrasounds. You say that you usually only pay a $50 copayment for doctor's visits. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 $50
copayment for each covered in-network specialist office visit, 20% coinsurance for surgical supplies, splints
and casts, and a $200 copayment for each in-network covered diagnostic radiology services in a provider's
office or freestanding radiology center.
You have been asked to pay a total of $263.32 for the specialist office visits, the surgical supplies, and the
ultrasounds. The specialist office visits fall within the "Physician/Practitioner services, including doctor's
office visits" benefits category. The surgical supplies and the ultrasounds fall 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 cost share for the specialist office visits, the surgical supplies, and the
ultrasounds provided on February 7, 2019 and April 1, 2019.