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

 
We decided that the Plan does not have to pre-approve a power scooter identified with code K0899. 
 
You asked the Plan to pre-approve a power scooter identified with code K0899. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a 
covered benefit. 
 
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.  
 
The file shows that you are requesting a power scooter with a code of K0899. Code K0899 is not listed as a 
covered product. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power scooter identified with code K0899.
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 doctor cannot give the enrollee an 
optimal level of care at the current facility. The Plan denied your request. The Plan says the enrollee's complex 
medical needs are being met in the current acute setting. 
 
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 the enrollee is receiving appropriate care at the present acute care facility. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 pre-approve repairs for your power wheelchair. 
 
You asked the Plan to pre-approve the repairs. You say that you need the repairs made to your wheelchair so 
that you can continue using it. The Plan denied your request. The Plan says Medicare does not cover repairs 
when the expense for repairs exceeds the estimated expense for replacement of the wheelchair. 
 
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 repairs have not been met. You asked for more repairs to your 
wheelchair. Per Medicare rules, the total of all repairs cannot be more than the cost of replacement. The cost of 
the repairs to your wheelchair are more than it will cost to replace the wheelchair. Please talk with your doctor 
and wheelchair provider for more options. Therefore, we decided that the Plan does not have to pre-approve 
repairs for your power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame/table system (E0637) and accessories 
(E1399) provided 
 
You asked the Plan to pre-approve a standing frame/table system and accessories. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The standing table at issue is considered a convenience item that is not primarily medical in nature. Therefore, 
we decided that the Plan does not have to pre-approve a standing frame/table system (E0637) and accessories 
(E1399) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery for use in hearing device (V5266). 
 
You asked the Plan to pre-approve the batteries. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the member can get the hearing aid batteries through the 
supplemental hearing vendor as an added benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the batteries may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Medicare does not cover hearing aids and batteries. The Plan added benefits 
program may cover hearing aids if the correct provider is used. To get hearing aids through this benefit please 
contact the supplemental hearing vendor. Therefore, we decided that the Plan does not have to pre-approve 
battery for use in hearing device (V5266).
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 it is your recommendation for an intensive acute 
rehab program to assist the enrollee back to his prior functional status and continued management of medical 
needs. You say that the enrollee currently meets the inpatient rehabilitation admission criteria. The Plan denied 
your request. The Plan says admission to an inpatient rehabilitation facility is not medically necessary. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to eat. The Plan denied your 
request. The Plan says dental services performed by an oral surgeon are not covered. 
 
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. Dental services performed by an oral surgeon are not covered. The 
health plan contract says that services must be performed by a participating general dentist. Therefore, we 
decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 28, 
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 according to the claims data available at the time of the review, the plan was unable to discover 
any evidence of an established relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that lab testing 
generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific 
medical problem.  
  
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services 
provided to the enrollee on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 24, 2020 through 
May 27, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The 
Plan denied your request. The Plan says that the stay is not medically necessary. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department (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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 24, 2020 through May 27, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 15, 
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 Medicare says screening services with no relation to a medical diagnosis of disease for the health 
of the patient are not a benefit. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the review indicates that there was no specific clinical rationale for the obtained laboratory studies. The 
services were not authorized because screening testing is not a Medicare benefit for the diagnoses as listed on 
the claim and are done for screening purposes. The review has determined that the laboratory services provided 
to the enrollee on January 15, 2020 were not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on January 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the aflibercept injections you received 
from your ophthalmologist from February 13, 2020 through April 16, 2020. 
 
You asked the Plan to waive the coinsurance for the aflibercept injections. You say that you had used Avastin 
previously but it was ineffective.  You stated that you were never told that your cost sharing would increase if 
you changed medications. The Plan denied your request. The Plan says you were charged this coinsurance 
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 20% 
coinsurance for Medicare-covered Part B drugs.  
 
You have been asked to pay 20% coinsurance for the aflibercept injections. The aflibercept injections fall 
within the Medicare-covered Part B drugs 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 the aflibercept injections you received from your ophthalmologist from February 13, 2020 through April 16, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L2397, L1851) provided March 20, 2020. 
 
You asked the Plan to pay for the orthotics. You say that the items were medically necessary. The Plan denied 
your request. The Plan says Medicare rules for telehealth services have not been met. 
 
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. 
There is no record of an established relationship between the Prescribing Physician and the enrollee. No 
records were provided by the enrollee's primary phyisician. 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 (L2397, L1851) provided March 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services the ambulance services provided on May 13, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that it took thirty minutes for the ambulance to 
arrive and by then your sister was on scene and assisted you with medications. The Plan denied your request. 
The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 13, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services the ambulance services 
provided on May 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 25, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were ill and passed out and that you 
were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says 
these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 25, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 25, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation and prophylaxis provided 
on June 17, 2020 by an OON provider. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that you were billed 
a net of $90, and reimbursement should be 50%, and you feel that you are to be reimbursed an additional $12. 
The Plan denied your request. The Plan says you received dental services from an OON dental provider. The 
Plan says that these services were covered at 50% of the allowed amounts, and you will not be reimbursed any 
additional amounts. 
 
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 are responsible for a 50% 
coinsurance for each cleaning and routine oral exam received OON. Therefore, we decided that the Plan does 
not have to pay more for the periodic oral evaluation and prophylaxis provided on June 17, 2020 by an OON 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the back brace provided on March 5, 2020. 
 
You asked the Plan to pay for the back brace. You say that the documentation supports the medical necessity of 
the back brace. The Plan denied your request. The Plan says none of the exams conducted were for the purpose 
of gathering subjective/objective information associated with the diagnosing, treating or managing the clinical 
condition for which the DME was ordered. 
 
The Plan must follow Medicare rules. Medicare rules say that back braces may be covered for an enrollee with 
one of the above listed conditions. 
 
In this case, several progress notes from the ordering physician were submitted for review. Only one, a note 
from January 14, 2020, is contemporaneous with the order dated March 2020. Another note is from 2018 and 
the next is from April 20, 2020. The January note does not document any back pain or any indication that a 
back brace was necessary or was planned. There is no documentation of any covered indication for this item. 
Therefore, we decided that the Plan does not have to pay for the back brace provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia services provided on April 26, 2019. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the enrollee enrolled in hospice from March 5, 
2019 through April 25, 2019. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 25, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia 
services provided on April 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 8, 
2020. 
 
You asked the Plan to pay for the services. You say that you were treated in place and not transported. The Plan 
denied your request. The Plan says if no transport of a Medicare beneficiary occurs, then there is no Medicare 
covered service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 8, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
February 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on January 21, 2020. 
 
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
drug test. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for a drug test provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous (IV) infusion hydration services rendered on 
February 11, 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 the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that hydration therapy services may not be used in addition 
to prolonged infusion services. 
 
We looked at the file and Medicare rules. The file shows that the hydration therapy was used in addition to 
prolonged infusion services. 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 pay for the intravenous (IV) 
infusion hydration services rendered on February 11, 2020.