Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve personal care services (T1019). 
 
You asked the Plan to pre-approve personal care services. The Plan denied your request. The Plan says this 
service is not a covered benefit under your plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of personal care services have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve personal 
care services (T1019).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises provided on July 3, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that the enrollee is enrolled in a dual plan and is 
entitled to approved services. The Plan denied your request. The Plan says there is no prior 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 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 therapeutic exercises provided on July 3, 2021, 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 to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee has no way to get around her 
home. The Plan denied your request. The Plan says the services are available in-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 Plan has network providers 
available who can provide the power wheelchair at issue at issue in this appeal. The requested seat elevation 
feature is not a covered benefit. We found no exception that would require the Plan to pre-approve the 
requested services. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair to be 
provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5267) and hearing aid supplies (V2560) 
received on May 20, 2022. 
 
You asked the Plan to pay for hearing aids and hearing aid supplies. You say that the items should be covered, 
and you want the Plan to pay. The Plan denied your request. The Plan says hearing aids obtained out-of-
network are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only you utilize an in-network provider.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids and hearing aid supplies have not been met. Specifically, the items were obtained out-
of-network and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids 
(V5267) and hearing aid supplies (V2560) received on May 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for outpatient dialysis and laboratory services 
provided from June 2, 2022 to June 30, 2022 
 
You asked the Plan to waive the cost share for the outpatient dialysis and laboratory services. You say that you 
would like the Plan to waive the cost share applied to the dialysis services received as the cost share creates a 
financial hardship. The Plan denied your request. The Plan says the cost sharing will be applied according to 
the Plan 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 20% 
coinsurance for each Medicare-covered dialysis treatment performed as an outpatient service, and a $15 
copayment for each in-network Medicare-covered lab test.  You have been asked to pay a 20% coinsurance for each in-network Medicare-covered outpatient dialysis 
treatment performed as an outpatient service.  You have been asked to pay a total of $60 for the lab services 
which is less than the standard $15 copayment for each in-network Medicare-covered lab test. 
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
PLANS 
SHARE 
 
COINSURANCE 
 
COPAYMENT 
June 2, 2022 J0882JA $384.36 $307.49 $76.87  
June 2, 2022 90999G5 $465.90 $372.72 $93.18  
June 4, 2022 90999G5 $465.90 $372.72 $93.18  
June 7, 2022 90999G5 $465.90 $372.72 $93.18  
June 7 ,2022 36415 $1.82   $1.82 
June 7, 2022 80053 $13.18   $13.18 
June 9, 2022 J0882JA $384.36 $307.49 $76.87  
June 9, 2022 90999G5 $465.90 $372.72 $93.18  
June 11, 2022 90999G5 $465.90 $372.72 $93.18  
June 14, 2022 90999G5 $465.90 $372.72 $93.18  
June 14, 2022 36415 $1.82   $1.82 
June 14, 2022 83550 $13.18   $13.18 
June 16, 2022 J0882JA $384.36 $307.49 $76.87  
June 16, 2022 90999G5 $465.90 $372.72 $93.18  
June 18, 2022 90999G5 $465.90 $372.72 $93.18  
June 21, 2022 90999G5 $465.90 $372.72 $93.18  
June 21, 2022 36415 $1.82   $1.82 
June 21, 2022 85018 $13.18   $13.18 
June 23, 2022 90999G5 $465.90 $372.72 $93.18  
June 25, 2022 90999G5 $465.90 $372.72 $93.18  
June 28, 2022 90999G5 $465.90 $372.72 $93.18  
June 28, 2022 36415 $1.82   $1.82 
June 28, 2022 85018 $13.18   $13.18 
June 30, 2022 J0882JA $384.36 $307.49 $76.87  
June 30, 2022 90999G5 $465.90 $372.72 $93.18  
TOTAL     $1,578.82 
 
The Medicare-covered outpatient dialysis treatments fall within the services to treat kidney disease benefit 
category. The laboratory tests fall under 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 cost share for outpatient dialysis and laboratory 
services provided from June 2, 2022 to June 30, 2022
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the comprehensive hearing test (92557) 
provided on April 4, 2022. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you do not 
believe you should be charged for this service. 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 $275 
copay for Medicare-covered outpatient hospital services.  
 
You have been asked to pay $137.27 for the comprehensive hearing test, which is less than the standard $275 
copay for Medicare-covered outpatient hospital 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 copayment 
for the comprehensive hearing test (92557) provided on April 4, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hospice room and board (T2046) provided from February 
1, 2022, to February 28, 2022. 
 
You asked the Plan to pay for the hospice care. You say that payment should be made. 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 hospice room and board (T2046) provided from February 
1, 2022, to February 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on March 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you were not aware you needed to have a prior 
authorization. You also say that a member services representative assisted you with scheduling the appointment 
and that she should have known that you needed a prior authorization. The Plan denied your request. The Plan 
says you must receive your care from a 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 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 an office visit provided on March 11, 2022, by an 
out-of-network (OON) provider.
Appeal type: Surgery
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 the enrollee has tried and failed 
conservative treatment without relief. You say that this procedure fills a treatment gap for enrollees that do not 
receive adequate relief from traditional conservative methods and this procedure is medically necessary. The 
Plan denied your request. The Plan says there are not enough studies to show Intracept is safe and effective to 
treat back pain. 
 
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 that the Intracept procedure is experimental.  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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve the requested services. You say that you are not able to get out of the chair 
without support. The Plan denied your request. The Plan says the criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. 
 
We looked at the file, and Medicare rules. The records do not show that you are completely unable to stand up 
from any chair in the home. Based on this information, we decided that Medicare rules for coverage have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency services provided on May 2, 
2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you should not be 
responsible to pay this because you were never seen by a doctor and laboratory services were not provided. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay $90 for emergency room services. This item/service falls within the emergency 
room visit benefit category. Records submitted support that laboratory services were provided. 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 emergency services provided on May 2, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the admission is medically necessary. The Plan 
denied your request. The Plan says admission was denied for skilled nursing care because the enrollee requires 
no nursing services which would be considered skilled services by Medicare. 
 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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee received oral medications, had stable vital signs, and her lungs were 
clear. The enrollee is at contact guard to stand by assist level for functional mobility including gait to 500 feet. 
The enrollee required varying assist with activities of daily living skills and had ongoing memory issues. The 
enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Our reviewer also found the 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided July 18, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. 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 $35 
copayment for in-network physician/practitioner services/specialist.  
 
You have been asked to pay a $35 copayment for specialist office visit. The total amount for the office visits is 
$70 ($35 x 2 = $70). However, you are only being asked to pay $45 ($22.50 x 2 = $45), which is less than the 
required amount. 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 specialist office visit provided 
July 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided from December 2, 2021 to December 13, 2021. 
 
You asked the Plan to pay for the IRF care. You say that the criteria for admission to the Acute Inpatient 
Rehabilitation setting has not been met. The Plan denied your request. The Plan says you feel it seems 
reasonable and logical that these services should be at least partially covered by the Plan since a hospital that 
works with the Plan suggested the rehabilitation hospital care. 
 
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 pay for the 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 the complexity of your nursing, medical and rehabilitation needs did not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
you did not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. Our physician reviewer also found that while the medical 
record supported a need for physical and/or occupational therapy, there was no documented need for intensive 
rehabilitation services. 
 
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 IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from December 2, 
2021 to December 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that the testing was necessary to treat the enrollee's 
advanced cancer. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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. 
 
We looked at the file and the rules. Although the test at issue is a covered test, the provider in this case is not a 
network provider with the Plan. The Plan did not pre-approve the test 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 
the lab testing services provided on March 3, 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 use of a ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that the enrollee has tried another device but did not feel 
benefit from it. The Plan denied your request. The Plan says a ventilator is not covered by Medicare for this 
purpose and the enrollee's needs could be met by a bilevel positive airway pressure device with safety tidal 
volume. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilator products used to provide continuous or 
bilevel positive airway pressure therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. A ventilator is not covered by Medicare for this purpose. Based on 
this information, we decided that Medicare rules for coverage of ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve use of a ventilator.