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

 
We decided that the Plan does not have to pre-approve Myopro powered upper extremity range of motion assist 
device 
 
You asked the Plan to pre-approve Myopro. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested item is not medically necessary. 
 
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 Myopro. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided, there is no documentation that the Myopro powered 
upper extremity range of motion assist device at issue in this case meets Medicare criteria for medically 
reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain utility 
compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home 
environment. In addition, records report the enrollee in this case has a right shoulder subluxation which may be 
a contraindication to use of the device. Although records from the device manufacturer/vendor argue medical 
necessity of the requested device, no records from the enrollee's actual treating provider clarify why the 
requested device is the most appropriate treatment for the enrollee's condition.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Myopro have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Myopro powered upper extremity range of motion assist device
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan of the whole 
body (78816) provided on February 28, 2022. 
 
You asked the Plan to pay for the PET scan. You say that you would like to know why a person with a cancer 
diagnosis would be denied a PET/computed tomography (CT) scan. The Plan denied your request. The Plan 
says the medical records provide no justification for the PET/CT scan. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 pay for the PET scan. Our reviewer says that the 
PET scan was not reasonable and necessary. Our physician reviewer found you did not have an indication for 
which a PET Scan could be covered at this time. 
 
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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pay for the positron emission tomography (PET) scan of the whole body (78816) provided on February 
28, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99284) provided on January 
30, 2021. 
 
 
 
 
 
 You asked the Plan to pay for the physician service. You say that the Medicare Advantage plan is the enrollee's 
primary insurance on the date of service in this case. You also say that this claim denied in error. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the emergency department visit (99284) provided on January 
30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the eyewear purchased on January 3, 2022. 
 
You asked the Plan to pay more for the eyewear. You say that your allowance could not have been exhausted. 
You also say that there was no previous frame allowance expenditure for which reimbursement was requested 
in 2022. The Plan denied your request. The Plan says your $250 eyewear benefit allowance was exhausted with 
this purchase.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to a $250 allowance for eyewear. 
 
We looked at the file and the Plan's rules. The record shows that your eyewear purchase cost a total of $349.98, 
your full $250 eyewear allowance was applied, and has been exhausted. You are responsible for the remaining 
amount of $99.98. Based on this information, we decided that the Plan's rules for coverage of the eyewear have 
not been met. Therefore, we decided that the Plan does not have to pay more for the eyewear purchased on 
January 3, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physical therapy visit provided on February 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for a therapy visit. You say that the denials do not acknowledge the medical 
necessity of the medical services provided. The Plan denied your request. The Plan says this service is not 
covered when received by an out-of-network provider. 
 
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 record does not show the Plan 
pre-approved 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 a physical therapy visit provided 
on February 8, 2022, 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 power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you have a hard time walking. The Plan 
denied your request. The Plan says you do not meet criteria for the requested item. 
 
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 patients 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 assistive mobility equipment, such as a four wheeled 
walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 the Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Intracept procedure is experimental. More research is needed before coverage can 
be approved. 
 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
November 30, 2020. 
 
You asked the Plan to pay for the nursing facility care. You say that the service should be covered. The Plan 
denied your request. The Plan says the enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on 
December 3, 2021. 
 
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by 
physician with written report. 
 
 
 We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with a 
place of service of 22 (outpatient hospital). This code is not payable to hospital outpatients or non-hospital 
enrollees. This means this claim is not payable as billed. Based on this information, we decided that Medicare 
rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not 
have to pay for the blood smear services coded 85060 provided on December 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says this service is not covered under the members benefit 
package. 
 
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, 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 
dental implants.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided 
from December 26, 2021, to December 30, 2021. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not given Xanax 
until your last night in the hospital, and feel that you were in the hospital longer than you would have been if 
you had received Xanax sooner. The Plan denied your request. The Plan says this claim was processed 
correctly, and your copayment was assessed in accordance with your contract. 
 
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 $225 
copayment for each of the first seven days of an inpatient hospital stay.  
 
You have been asked to pay a $900 copayment for four days of inpatient hospital care ($225 x 4 = $900). 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 inpatient hospital admission provided from December 
26, 2021, to December 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. You say that there is no agreement that the codes are included in 
the dialysis rate. The Plan denied your request. The Plan says the services are the responsibility of the dialysis 
center. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab testing services provided on December 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 29, 2022, 
to February 27, 2022. 
 You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's 
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 29, 2022, to February 27, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on August 18, 
2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that you decided to do laser treatment 
without using insurance so an official office visit did not take place. The Plan denied your request. The Plan 
says the copayment 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). Your contract with the Plan clearly says that you must pay $25 for 
each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay $25 for the office visit. The office visit falls within the Physician/Practitioner 
Services, Including Doctors Office Visits 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 outpatient office visit provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on December 7, 2020. 
 
You asked the Plan to pay for the testing services. You say that the test results were needed to determine the 
course of treatment. The Plan denied your request. The Plan says the management plan was already determined 
prior to the testing. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation.  
 
We looked at the file and Medicare rules. The medical records provided do not show that the enrollees treating 
physician ordered the testing or would use the results in the management of a specific medical problem. The 
records do not clearly document the physicians intent for the test to be performed. The testing is not covered 
by Medicare for screening purposes. 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 gene panel testing 
provided on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a standard power operated vehicle. You say that the requested power 
operated vehicle is a necessity for your care. The Plan denied your request. The Plan says rules for coverage 
fora PMD have not been met. 
 
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 patients 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 does not show that you have a mobility deficit that impairs your participation in MRADLs nor that 
your condition cannot be improved by a walker, cane or manual wheelchair. 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 standard power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care provided on January 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the nursing facility care. You say that the service was rendered to the enrollee 
out of medical necessity, and you would like the claim reprocessed for payment. The Plan denied your request. 
The Plan says the rendering provider is an OON provider and there was no referral from an in-network 
provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 nursing facility care provided on January 3, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinalysis services received on March 1, 2022. 
 
You asked the Plan to pay for the urinalysis services. You say that you would like the plan to reconsider their 
decision. The Plan denied your request. The Plan says the claim must be submitted to your primary insurance 
first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
 The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the urinalysis services until the primary insurer has denied the claim for these services. Therefore, we 
decided that the Plan does not have to pay for the urinalysis services received on March 1, 2022.