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

 
We decided that the Plan does not have to pre-approve a power seat elevation feature, expandable controller, 
harness, and electronic connection device for a power wheelchair. 
 
You asked the Plan to pre-approve power seat elevation feature, expandable controller, harness, and electronic 
connection device. You say that the enrollee needs this equipment. The Plan denied your request. The Plan says 
the enrollee's upper limb strength and function are adequate for the enrollee to control power options using 
their own switches. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not covered by 
Medicare because it is not primarily medical in nature. 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 power seat elevation feature, 
expandable controller, harness, and electronic connection device. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has adequate strength to manage the standard switches on a power wheelchair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power seat elevation feature, expandable controller, harness, and electronic 
connection device have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation feature, expandable controller, harness, and electronic connection device for a power 
wheelchair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services for drug testing provided on May 10, 2022. 
 
You asked the Plan to pay for lab services for drug testing. You say that this was medically necessary and 
should be covered. 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 lab services for drug 
testing provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the naturopathy services (99213, 99214, 
97140), provided on June 1, 2022, through June 11, 2022. 
 
You asked the Plan to waive the copayment for the naturopathy services. You say that the services should be 
covered. 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 naturopathy.  
 
You have been asked to pay a $20 copayment for the naturopathy services. This item/service falls within the 
naturopathy 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 naturopathy services 
(99213, 99214, 97140), provided on June 1, 2022, through June 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you were approved for a total 
knee arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says 
there is no documentation provided to support the expectation that you will require a greater than 2 midnight 
stay. 
 
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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found you are approved for a total knee arthroplasty. The record does not 
document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and sales tax (S9999), 
provided on March 10, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator and sales tax. You say that the items should be covered. 
The Plan denied your request. The Plan says this was obtained out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 oxygen concentrator (E1390) and sales tax 
(S9999), provided on March 10, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full mouth debridement services (D4355) provided on 
November 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your $3,500 dental benefit maximum allowance 
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 date of service August 9, 2022. 
Therefore, we decided that the Plan does not have to pay for full mouth debridement services (D4355) provided 
on November 10, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 11, 
2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the copayment. 
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 $165 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $165 copayment for an ultrasound. However, you are only being charged 
$110.60 which is less than the required amount. This item/service falls within the outpatient diagnostic tests 
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 ultrasound provided on 
October 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and suspension 
sleeves (E0673). 
 
You asked the Plan to pay for a pneumatic compression device and suspension sleeves. You say that the items 
should be covered. The Plan denied your request. The Plan says these items were not used in the members 
home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a pneumatic compression device and suspension sleeves was used in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and 
suspension sleeves (E0673).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on October 31, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 date of service March 23, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a quickie backpack (K0108). 
 
You asked the Plan to pre-approve a quickie backpack. You say that the requested item is medically necessary. 
The Plan denied your request. The Plan says that the requested item is not primarily medical in nature and 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 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 quickie backpack (K0108).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional PT visits. 
 
You asked the Plan to pre-approve the therapy services. You say that you are appealing the denial of 6 
additional PT visits. The Plan denied your request. The Plan says the request is 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 the therapy services. 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 the additional requested therapy generally is not accepted as 
specific and effective therapy for the patient condition beyond what was approved by the Plan. The enrollee has 
had prior therapy and the documentation does not reveal that the enrollee requires the unique skills of a 
professional therapist to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or by or under the supervision of a therapist. The patient can transition to an 
independent home exercise program. 
 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 6 additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital level of care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the inpatient level of care 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient care are met. Our physician 
reviewer found you are approved for an elective shoulder surgery. The planned procedure is not on the 
inpatient-only list and is approved at the outpatient level of care. There is no documentation supporting that 
you will require at least two midnights of inpatient care for the approved procedure. The inpatient admission is 
not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital level of care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs 
provided on June 11, 2021. 
 
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree 
with the coinsurance.. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs. This item/service falls 
within the Medicare Part B prescription 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 Medicare Part B prescription drugs provided on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the SSBCI benefits. 
 
You asked the Plan to pre-approve the SSBCI benefits. You say that you have been eligible for the SSBCI 
benefits in the past, you are not sure why you are not this year. The Plan denied your request. The Plan says 
your provider has attested that you do not meet all three of the criteria. Therefore, you do not qualify for 
services under SSBCI program. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with an eligible chronic condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the SSBCI benefits have not been met. Specifically, we have confirmed that you do not have one 
of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have 
to pre-approve the SSBCI benefits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Detect (0012M) provided June 29, 2022. 
 
You asked the Plan to pay for Cxbladder Detect. You say that you believe the evidence supporting the use of 
Cxbladder as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says Cxbladder test is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Cxbladder Detect have not been met. Therefore, we decided that the Plan does not have to pay for 
Cxbladder Detect (0012M) provided June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility care visit provided on January 10, 2022. 
 
You asked the Plan to pay for a nursing facility care visit. You say that treatment was medically necessary and 
rendered in good faith. 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 a nursing facility care 
visit provided on January 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for bladder surgery provided on September 22, 
2022. 
 
You asked the Plan to reduce the cost share for the surgical services. You say that you were not aware the 
facilities were out-of-network. 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 20% 
coinsurance for out-of-network outpatient surgery.  
 
You have been asked to pay a total of $634.16, which is 20% coinsurance of the allowed amount for the 
surgical services ($7.02 coinsurance + $598.01 coinsurance + $29.13 coinsurance = $634.16). These 
items/services falls within 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 reduce the 
cost share for bladder surgery provided on September 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation (TENS) 
device billed for date of service October 18, 2022. 
 
You asked the Plan to pay for the billed services. You say that the code is an accepted procedure code. The 
Plan denied your request. The Plan says the billed code cannot be verified. 
 
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 relevant medical records which support medical necessity for the supplies provided 
in this case. Based on this information, we decided that the Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulation 
(TENS) device billed for date of service October 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for a denosumab injection provided on June 2, 
2022. 
 
You asked the Plan to reduce the cost share for the injection. You say that in the past you were charged a flat 
copayment and not a coinsurance. 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 20% 
coinsurance for Medicare-covered Part B medications.  
 
The record shows this claim was approved and you are responsible for the cost sharing amount. You have been 
asked to pay a total of $266.98, which is 20% coinsurance of the allowed amount for the injection and 
therapeutic services ($11.86 coinsurance + $255.12 coinsurance = $266.98). This item/service falls within the 
Medicare Part B prescription 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 reduce the cost share for a 
denosumab injection provided on June 2, 2022.