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

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 14. 
 
You asked the Plan to pre-approve the dental service. You say that the crown got approved. You say that you 
cannot afford to pay for the core build up. The Plan denied your request. The Plan says core build up is not 
listed as a covered service. 
 
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 pre-approve core 
build up (D2950) for tooth # 14.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued stay in the SNF. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF.  
 
You do not have complex wound care or other ongoing SNF level SN need. Your functional level does not 
require ongoing skilled therapy services with the specialized skill, knowledge and judgment of a qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. You do 
not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in 
a SNF. As a practical matter, you do not require continued services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve continued stay in the SNF.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 motion assist device (L8702). 
 
You asked the Plan to pre-approve a MyoPro 2 motion assist device. You say that traditional rehabilitation has 
failed the enrollee. The Plan denied your request. The Plan says this is experimental. 
 
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 MyoPro 2 motion assist device. Our 
reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the 
patient's medical condition/function of hemiparesis after stroke than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to 
improve the functioning of a malformed body member. 
 
 
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 MyoPro 2 motion assist device have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro 2 motion assist device (L8702).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve private duty nursing care to be performed by a non-
participating provider. 
 
You asked the Plan to pre-approve the services. You say that you cannot do daily living needs. The Plan denied 
your request. The Plan says the private duty nursing coverage/home health aide is not coverable by Medicare. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 physician reviewer 
found the records do not show that skilled nursing services are required to effectively provide treatment, care, 
and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain 
your condition and/or prevent deterioration. There are no complex wounds, new enteral feedings or other 
skilled nursing (SN) need. The records do not show that skilled therapy is needed to effectively provide 
treatment, care, and/or services in order to improve your level of function, or to establish/perform a 
maintenance program to maintain your level of function and/or prevent deterioration. As you do not require 
 
 
skilled therapy or skilled nursing services you do not meet the definition of home health aide services per 
Section 50.2 and the request for home health aide services are not reasonable and necessary to the treatment of 
your illness or injury by the skilled professional staff. 
 
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 private duty nursing care to be performed by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foam roller. 
 
You asked the Plan to pre-approve a foam roller. You say that you lay on your neck and roll back and forth to 
loosen the tension on your neck and pain relief. The Plan denied your request. The Plan says this item is not 
covered under Medicare or the Health Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a foam roller.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 24, 2019. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 Guardant360 testing is not supported in the medical record. Specifically, this service should be 
coded with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe air conditioner received on March 30, 2020.You asked the Plan to pay forthe air conditioner. You say that you were informed that you were entitled to a reimbursement of $150 for an air conditioner unit for the summer heat.The Plan denied your request. The Plan says the item received is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan'scoverage rules apply in this case. The Plan covers these services whenyou are diagnosed with COPD and the items are received by a participating provider.The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Thisitem is available to the general public and would be helpful even to those who are not sick or injured.While your plan does cover this item, it will only cover this item is you have been diagnosed with COPD and the item is received by a participating provider. Review of the file does not support that you have COPD and the item received was not provided by a participating provider. Therefore, we decided that the Plan does not have to pay forthe air conditioner received on March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visits (99213) provided on January 3, 2019 
through December 2, 2019. 
 
You asked the Plan to pre-approve the office visits. You say that you would like reconsideration because you 
were referred for these services by your PCP. The Plan denied your request. The Plan says you did not obtain a 
referral from your PCP for these visits. 
 
Medicare rules say that plans may require prior authorization. 
 
Per your EOC, this service requires a referral from your PCP. The record does not indicate that you obtained a 
referral for these services. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits (99213) 
provided on January 3, 2019 through December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy services (77280, 77336, 
77412) received on February 4 to February 25, 2020. 
 
You asked the Plan to waive the copayment for radiation therapy services. You say that the copayment for 
these services should be reconsidered. The Plan denied your request. The Plan says the correct copayment 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 a $60 
copayment for each Medicare-covered radiation therapy service.  
 
You have been asked to pay $960, or a $60 copayment for 16 radiation therapy services. Radiation therapy 
services 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 copayment for radiation therapy services (77280, 77336, 77412) received 
on February 4 to February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
April 23, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that medically necessary services were provided in 
good faith. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services by an out-of-network providers. 
 
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 subsequent nursing facility care (99308) 
provided on April 23, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the specialist service provided on June 29, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the enrollee did not see a 
specialist, she saw a nurse practitioner. The Plan denied your request. The Plan says the copay was applied 
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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $40 copay for each covered visit or consultation in an outpatient location with a specialist.  
 
The documentation shows that the enrollee received services at a gastroenterology office. The enrollee has 
been asked to pay a $40 copay for the services provided. The services fall within the physician services benefit 
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the 
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. 
Therefore, we decided that the Plan does not have to waive the copay for the specialist service provided on 
June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cataract surgery provided January 13, 2020 to February 5, 
2020. 
 
You asked the Plan to pay for the cataract surgery. You say that the services were medically necessary and 
should be covered. The Plan denied your request. The Plan says except for emergency care, services provided 
outside the United States are not covered. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, and pre-approved 
care.   
 
We looked at the file, and Medicare rules. The services were not emergent. The record shows the enrollee 
opted to travel to Ecuador to have the surgery performed. Based on this information, we decided that Medicare 
rules for coverage of the cataract surgery have not been met. Therefore, we decided that the Plan does not have 
to pay for cataract surgery provided January 13, 2020 to February 5, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care provided on May 10, 
2020 by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the nursing homes obtain the 
authorizations, and your company leverages that authorization to have your claims processed. The Plan denied 
your request. The Plan says this service was rendered by an OON provider. The Plan also says that there was 
no authorization on file. 
 
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 
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 subsequent nursing facility care provided on 
May 10, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a catheter placement (36556) provided January 5, 2020 
 
You asked the Plan to pay for the catheter placement. You say that these services were medically necessary. 
The Plan denied your request. The Plan says the claim was billed with an invalid modifier. 
 
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 36556 is not supported in the medical record. Specifically, the record shows this CPT 
code was billed with an invalid modifier. Based on this information, we decided that Medicare rules for 
coverage of the catheter placement have not been met. Therefore, we decided that the Plan does not have to pay 
for a catheter placement (36556) provided January 5, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM 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 a continuous glucose monitor can be covered if 
the enrollee is insulin-treated with multiple (three or more) daily injections of insulin and checks their blood 
glucose levels four or more times daily. 
 
We looked at the file and Medicare rules. The records show you inject insulin twice daily, and check your 
blood glucose levels twice daily. This does not meet Medicare criteria for a CGM. Based on this information, 
we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Continuous Glucose Monitor (CGM) (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the specialist services provided on July 27, 
2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were not seen for what you 
thought you were there for. The Plan denied your request. The Plan says the claim processed correctly 
assessing the copay. 
 
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 $35 
copay for each specialist visit.  
 
You have been asked to pay a $35 for the specialist visit. The services fall within the physician services benefit 
category. The copay is not determined by the quality of care, or the outcome of 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 copay for the specialist services provided on July 27, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional personal care assistant services. 
 
You asked the Plan to pre-approve additional personal care assistant services.. You say that you have had four 
hours of care services in the past and need to continue. The Plan denied your request. The Plan says your needs 
can be met with fewer hours of service. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered. 
 
We looked at the file and Medicare rules. The requested services are custodial in nature and are not covered 
under Medicare. Based on this information, we decided that Medicare rules for coverage of additional personal 
care assistant services. have not been met. Therefore, we decided that the Plan does not have to pre-approve 
additional personal care assistant services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay from 
January 31, 2020, to February 4, 2020. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you disagree with 
the charges because the stay is related to ongoing treatment. 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 $750 
copayment for inpatient hospital care.  
 
You have been asked to pay a $750 copayment for an inpatient rehabilitation stay. An inpatient rehabilitation 
stay falls within the inpatient hospital 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 an inpatient rehabilitation stay from January 31, 2020, to February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on May 20, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. 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 
services at issue. 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 domiciliary, rest home visit provided on May 20, 2020.