Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the wound debridement services you 
received at an outpatient hospital facility. 
 
You asked the Plan to waive the copayments for the wound debridement services. You say that your doctor 
referred you to this wound care clinic.  You say that this facility did the same service that your doctor did in his 
office but they are charging you a surgical copayment. The Plan denied your request. The Plan says you were 
charged these copayments 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 $250 
copayment for outpatient surgery and other services in a hospital facility.  
 
You have been asked to pay a $250 copayment for the wound debridement services. Since you had these 
services at an outpatient hospital facility, the wound debridement services fall within the outpatient surgery and 
other services in a hospital facility 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 
the wound debridement services you received at an outpatient hospital facility.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for enteral formula (B4152) provided. 
 
You asked the Plan to pay for the enteral formula. You say that the items were medically necessary. The Plan 
denied your request. The Plan says documentation does not support the services billed. 
 
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. There was no 
itemized invoice or shipping record. 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 enteral 
formula (B4152) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two indirect pulp caps provided on June 1, 2020. 
 
You asked the Plan to pay for the indirect pulp caps. You say that the dentist said that 2 fillings were cracked, 
and needed to be replaced. You also say that you were charged for services that were supposed to be covered 
under your dental plan. The Plan denied your request. The Plan says your contract does not provide coverage 
for dental pulp caps of any type. The Plan also says that you signed a treatment plan at the provider's office 
acknowledging that you would be fully responsible for these charges because they 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. Therefore, we decided that the Plan does not have to pay for the two 
indirect pulp caps provided on June 1, 2020.
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. The Plan denied your request. The Plan says there is no need for 
physician supervision 3 times per week, or an intensive multidisciplinary approach to daily therapy. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute hospital with symptomatic right knee arthritis. He underwent an 
uncomplicated total knee arthroplasty. He is walking 270 feet with a rolling walker with stand-by to contact 
guard assistance, and is contact guard assist for transfers. The complexity of the enrollee's nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. He does require physical and occupational therapy, but does not require an intensive 
inpatient rehabilitation therapy program in an inpatient rehabilitation facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinary catheter (A4352KX) provided on June 17, 2020, 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the urinary catheter. You say that you were not notified prior authorization was 
required. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the 
provider; therefore, payment has been correctly denied. 
 
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 urinary catheter (A4352KX) provided on June 
17, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy services provided by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 home infusion therapy services provided 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 provided on April 17, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 the laboratory services are not supported in the medical record. Specifically, the documentation 
submitted did not support that the laboratory testing was performed with blood sampling. The lab requisition 
shows a urine sample was collected. Based on this information, we decided that Medicare rules for coverage of 
the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 heavy duty, multiple power 
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds (CPT Code K0862) and the other 
requested items/accessories. 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the member does not have a qualifying diagnosis for K0862 heavy duty group 3 power 
wheelchair. 
 
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 DME. Our physician reviewer 
found the documentation does not support that the Group 3 Power wheelchair K0862 is medically necessary. 
The enrollee does not have a diagnosis of a neurological condition, myopathy, or congenital muscle deformity. 
As the Group 3 Power Wheelchair with multiple power options is not reasonable and necessary, none of the 
requested accessories can be covered. 
 
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 DME have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient 
weight capacity 301 to 450 pounds (CPT Code K0862) and the other requested items/accessories.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed Tomography Angiography (CTA) of the 
abdomen (74175). 
 
You asked the Plan to pre-approve the CTA scan. You say that the CTA is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 CTA scan. Our reviewer says that 
the requested scan is not medically necessary. Our physician reviewer found the abdominal exam performed is 
normal. The weight loss documented coincides with dietary changes. The plan proposed alternative Abdominal 
CT scan is more appropriate than the requested Computed Tomography Angiography, which is not supported 
by the documentation provided. 
 
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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Computed Tomography Angiography (CTA) of the abdomen (74175).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care you received on June 
26, 2020. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each Medicare-covered emergency room visit.  
 
Review of the file shows that you were provided emergency care on June 26, 2020. You have been asked to 
pay a $90 copayment for the services. The services fall 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 care you received on June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle. 
 
You asked the Plan to pre-approve a scooter. You say that you can ambulate around the house but out in public 
you cannot. The Plan denied your request. The Plan says the evaluation shows your mobility needs within your 
home can be resolved with a cane and front wheeled walker. 
 
 
 
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 your condition can be improved by a walker or cane. Also, the item at issue in this appeal is 
being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan 
cover PMDs for use only outside the home. 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 Group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan 
denied your request. The Plan says the power options can be controlled with their own switches. 
 
 
 
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when medically 
necessary per the above guidelines. 
 
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 an expandable controller. Our reviewer 
says that the requested items are not medically necessary. Our physician reviewer found your upper extremity 
strength and function are sufficient for you to control any power options through their own individual switches. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377, E2311, E2313).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible the injection procedure you had on June 12, 
2020. 
 
You asked the Plan to waive the deductible the injection procedure. You say that you have had this injection 
procedure for the past two years and haven't been billed before. The Plan denied your request. The Plan says 
you had not yet met your annual deductible when you had this injection. The Plan says that in prior years, you 
had already met your deductible when you had these injections. 
 
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 a $750 annual deductible that must be met before the Plan will pay for 
your care.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 annual 
deductible that must be paid before the Plan will pay for your care. This cost sharing is a contractual obligation 
that had not been met at the time the injection procedure was received on June 12, 2020. Therefore, we decided 
that the Plan does not have to waive the deductible the injection procedure you had on June 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not 
have acute symptoms that require 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from November 4, 2020, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking 
place beyond the date in question. The services were not reasonably expected to improve your condition, or for 
the purpose of diagnosis. The records were supervised and evaluated by a physician. Based upon review the 
records, you were not shown to be a danger to yourself or others. You were not showing any auditory or visual 
hallucinations. You were cooperative/compliant with treatment, while not showing any threats the safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that you had several 
appointments, but your shoulder and hand are not functional yet. You say that you are in a lot of pain and want 
to resume therapy as soon as possible. The Plan denied your request. The Plan says additional visits are not 
medically necessary. 
 
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 10 additional physical therapy visits. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of the enrollee's condition. Our physician reviewer found that you had prior therapy for this 
condition and had home exercise instruction. Our reviewer says that the unique skills of a professional therapist 
are not required to safely and effectively provide ongoing treatment. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe outpatient surgery services provided from June 15, 2020, to June 17, 2020.You asked the Plan to waive the copay forthe services provided. You say that you live on a fixed income.The Plan denied your request. The Plan says the copay was applied based on your benefits.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 $325 copay for outpatient surgery. You have been asked to pay a $325 copay for the services provided. The services fallwithin the outpatient surgery 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 copay forthe outpatient surgery services provided from June 15, 2020, to June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgery, crushing of stone in urinary duct 
(ureter) with stent using an endoscope provided on July 23, 2020. 
 
You asked the Plan to waive the coinsurance for surgery, crushing of stone in urinary duct (ureter) with stent 
using an endoscope. You say that you called previous to your procedure to get an estimate and don't feel like 
you should have to pay the increased amount. The Plan denied your request. The Plan says the correct cost 
share was 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 20% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay 20% coinsurance for crushing of stone in urinary duct (ureter) with stent using an 
endoscope. This service falls within the Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers 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 surgery, crushing of stone in urinary duct (ureter) with stent using an endoscope provided on July 23, 2020.  
 
Your complaint about potentially being told the service would be less then what was billed is not a valid appeal 
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020, by an out-
of-network (OON) provider. 
 
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 were rendered by an out-of-network provider without 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 medical services provided on April 16, 2020, 
by an out-of-network (OON) provider.