Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from August 17, 2022, 
to August 18, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the enrollee was told in the emergency 
room that they had a blood clot in their right lung. You also say the enrollee was diagnosed with COVID-19. 
The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare or the 
enrollee's plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 pay for the self-administered drugs 
provided from August 17, 2022, to August 18, 2022.  
 Benefits for the self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88305 and 88307) provided on 
October 29, 2021. 
 
You asked the Plan to pay for the laboratory services (88305 and 88307). You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says this claim is a duplicate of a 
previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 21, 2021. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date. 
Based on this information, we decided that the Medicare rules for the laboratory services (88305 and 88307) 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (88305 
and 88307) provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing exam provided 
on July 28, 2022. 
 
You asked the Plan to waive the copayment for the comprehensive hearing exam. You say that you are 
requesting reimbursement for the hearing test. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $20 
copayment for Medicare-covered hearing exam.  
 
You have been asked to pay a $20 copayment for the comprehensive hearing exam. This comprehensive 
hearing exam falls within the hearing services 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 comprehensive hearing exam provided on 
July 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an in-network exception for diabetic supplies to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an in-network exception. The Plan denied your request. The Plan says 
services are available within the 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The enrollee does have out-of-
network benefits at a higher cost share. There are also in-network providers available for the items at issue. We 
found no exception that would require the Plan to pre-approve an in-network exceptions for the requested 
items. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for diabetic 
supplies to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Purewick collection system and supplies. 
 
You asked the Plan to pre-approve a Purewick collection system and supplies. You say that the Purewick 
system is medically necessary. The Plan denied your request. The Plan says the Purewick system is non-
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a Purewick collection system and 
supplies have been met. Specifically, the case file shows that the Plan requested recent medical records from 
the prescribing provider. There were no medical records supplied, beyond the prescription written for the items 
in dispute.  Therefore, we decided that the Plan does not have to pre-approve a Purewick collection system and 
supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary to help the 
enrollee achieve increased mobility to ensure a safe return home. The Plan denied your request. The Plan says 
the member's medical and therapy needs could be met in a skilled nursing unit. 
 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
  
 
 
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 enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve mental health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the mental health services. You say that you would like to continue with this 
provider since the treatment is effective. The Plan denied your request. The Plan says network providers are 
available to provide necessary care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. 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 
mental health services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee's care can be provided in 
the current inpatient hospital. The enrollee may be ready to move to another setting in the future. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided on May 23, 2022. 
 
You asked the Plan to pay for the mental health services. You say that the provider depends on hospital staff to 
obtain authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the mental health 
services provided on May 23, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for radiation therapy provided from May 5, 
2022, to June 14, 2022. 
 
You asked the Plan to waive the copayment for radiation therapy. You say that you cannot afford this charge. 
The Plan denied your request. The Plan says this cost sharing was charged 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 $60 
copayment for each radiation therapy visit.  
 
You have been asked to pay a $60 copayment per radiation therapy visit. This item/service falls within the 
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for radiation therapy provided from May 5, 2022, to June 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 15, 2022. 
 
You asked the Plan to pay for the ambulance response. You say that you would like this service covered. The 
Plan denied your request. The Plan says this service is not covered when there is no transport. 
 
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 August 15, 2022. 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 response and treatment with no 
transport (A0998) provided on August 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) and complete series of 
intraoral x-rays (D0210) provided on August 17, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that this office was OON 
until after services were received. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral exam (D0150) and complete series of intraoral x-rays (D0210) provided on 
August 17, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on August 23, 
2022. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that you were not able to leave the 
facility to see a different provider at the time. The Plan denied your request. The Plan says that unauthorized, 
out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the domiciliary or rest 
home visit provided on August 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health therapy services. 
 
You asked the Plan to pre-approve the home health therapy services. You say that you are upset as you had no 
idea about this appeal and that it has been a lot of back and forth.  The Plan denied your request. The Plan says 
we made multiple attempts to get an order and your care plan from your doctor's office but we did not receive 
them. Therefore, we cannot make a decision on medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health therapy services have 
been met. It has not been shown that the Plan should cover your request due to the missing medical records.  If you would still like coverage, you or the provider should submit a new request to the Plan with supporting 
records. Therefore, we decided that the Plan does not have to pre-approve home health therapy services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity. 
 
You asked the Plan to pre-approve Trulicity. You say that the enrollee has been on this drug since October 25, 
2021. You also say that their A1C has improved. The Plan denied your request. The Plan says the requested 
drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part 
D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered 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 Trulicity.  
 Benefits for Trulicity 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 11, 2022, 
to March 12, 2022. 
 
You asked the Plan to pay for the home health services. You say that the NOA is only required for the 
enrollee's initial visit. The Plan denied your request. The Plan says the claim has not been billed with the 
correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We looked at the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from February 11, 2022, to March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the teeth cleaning (D1110) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the service should be covered. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on dates of service March 9, 2022, and June 
29, 2022. Therefore, we decided that the Plan does not have to pay for the teeth cleaning (D1110) provided on 
November 2, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 23, 2022, through 
May 26, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient hospital care provided was 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient 
hospital care provided was 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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on May 23, 2022 with a chief complaint of 
left flank pain during hemodialysis. He also complained of dysuria but denied hematuria. He denied any trauma 
or fevers. The enrollees primary medical history includes End Stage Renal Disease (ESRD) secondary to 
congenital renal disease and a neurogenic bladder. He also has a history of a suprapubic catheter but was 
changed to a foley catheter. The enrollee was found to have a urinary tract infection. Per the Urologist, the 
foley catheter had malfunctioned. The review indicates that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the enrollees necessary hospital care (including 
earlier 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from May 23, 2022, through May 26, 2022.  
 
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.