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

 
We decided that the Plan does not have to pay for the knee orthosis (L1851x2) and suspension sleeve 
(L2397x2) provided October 20, 2021. 
 
You asked the Plan to pay for the orthoses. You say that the enrollee had an in-person visit within 6 months of 
the signed order and the primary care physician prescribed him the knee braces. The Plan denied your request. 
The Plan says the records do not support the need or justification for the braces. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the orthoses have not been met. Specifically, the documentation submitted does not include a valid 
signature from the persons responsible for the care of the beneficiary. the pre-printed form from the supplier 
has a copied signature. The submitted records are from an office visit the prior year on October 22, 2020. The 
Plan verified with the ordering provider's office indicated that there is no documentation that the doctor ordered 
the braces. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851x2) and 
suspension sleeve (L2397x2) provided October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested provider. You say that have 
had bilateral cataract surgeries with this provider and you wish to stay with the provider even though the 
services are out-of-network. The Plan denied your request. The Plan says in cases where services cannot be 
reasonably obtained by a network provider, out-of-network services can be rendered if the services are a 
covered benefit, are medically necessary and when a prior authorization is attained. The Plan will not deny an 
out-of-network request if there are no in-network providers available to provide medically necessary service. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for emergency services provided on February 19, 2022. 
 
You asked the Plan to pay for the emergency services. You say that you have provided a copy of your 
certification and other supporting documents for this claim. The Plan denied your request. The Plan says that 
the provider is not eligible to bill Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that the provider is not eligible 
to bill Medicare. However, with your appeal request, you submitted a copy of the certification letter you 
received from the Center for Medicare and Medicaid Services that explicitly states that your organization was 
granted Medicare billing privileges during the COVID-19 public health emergency. The Plan has not 
challenged this document.  In fact, the Plan has made no effort at all to even address this document. This 
certification letter directly contradicts the Plan's only argument.  THe burden is on the Plan to support its denial 
and they have failed to do so in this case. Therefore, we decided that the Plan has to pay for emergency services 
provided on February 19, 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.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need 
additional transportation trips to get to your doctor's appointments. The Plan denied your request. The Plan says 
you have exhausted your 20 one-way transportation trips for 2022. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 20 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 
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 Euflexxa, have been met. In this case, 
the Plan sent several requests for medical records to the provider but no information was returned. Therefore, 
there is not enough information provided to determine if the Plans step therapy criteria have been met.  
Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye surgery services provided on December 3, 2021, to 
December 31, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the eye surgery services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advance. 
 
 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 eye surgery services provided on December 3, 
2021, to December 31, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for twenty (20) additional routine transportation 
trips. 
 
You asked the Plan to provide coverage for twenty (20) additional routine transportation trips. You say that you 
need additional transportation trips to get to the required appointments that you cannot miss. The Plan denied 
your request. The Plan says you have already used the 10-one way transportation trips to Plan-approved 
locations allowed. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 We looked at your request, the records in the case file, and the rules. The file shows that you have used the 
maximum allowed 10 one-way transportation trips this year. Therefore, we decided that the Plan does not have 
to provide coverage for twenty (20) additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics. 
 
You asked the Plan to pay for foot orthotics. You say that although you are not diabetic, you believed these 
orthotics would be covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical access to an implant body (second stage 
implant surgery) (D6011). 
 
You asked the Plan to pre-approve second stage implant surgery. You say that the enrollee needs this service. 
The Plan denied your request. The Plan says this service is not covered under the enrollee's 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. 
 
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 
surgical access to an implant body (second stage implant surgery) (D6011).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82728, 83540, 83550) provided December 28, 
2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the lab services are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory test is ordered for the treatment of 
End-Stage Renal Disease, then the laboratory test is not paid separately. 
 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The lab services were related to dialysis treatment and are not 
separately payable. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82728, 83540, 
83550) provided December 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the joint survey (code 77077) provided on November 3, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the joint survey. You say that the patient cannot choose which provider reads 
their diagnostic tests. The Plan denied your request. The Plan says unauthorized, non-plan 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 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 joint survey (code 77077) provided on 
November 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 lightweight portable power wheelchair for the 
enrollee. 
 
You asked the Plan to pre-approve a lightweight portable power wheelchair. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the physician notes do not note that the enrollee is 
unable to perform activities of daily living in the home or that an appropriately-fitted cane or walker will not 
help you. 
 
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 the enrollee does not have a mobility deficit that impairs his participation in MRADLs, his 
condition cannot be improved by a walker, cane or manual wheelchair or that the enrollee can safely operate 
the PMD being requested. 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 lightweight portable power wheelchair for 
the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this care is medically necessary. 
The Plan denied your request. The Plan says while the criteria for observation care was met, the criteria for 
acute inpatient care was not met. 
 
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 payment are met in this 
case. Our physician reviewer found that the review indicates that the enrollee was a then, 86-year-old male with 
dementia, hypertension, and hyperlipidemia who comes in from his assisted living facility. He was evaluated in the emergency department and found to be pleasantly confused. A chest X-ray showed nothing acute. A 
computed tomography (CT) scan of the brain showed multiple old infarcts, but nothing acute. 
Electrocardiogram showed normal sinus rhythm with evidence of septal infarct. The review has determined that 
record did not show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the knee provided on November 18, 2021 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-ray. You say that the patient cannot chose which radiologist reads their 
diagnostic tests. The Plan denied your request. The Plan says unauthorized, non-plan 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. 
 
Neither the provider of service nor the referring provider is 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 x-ray of the knee provided on 
November 18, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from May 5, 2020, 
through May 21, 2020. 
 
You asked the Plan to pay for the inpatient hospital services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says this claim cannot be paid 
as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for diagnosis codes that are listed on CMS POA 
exempt list, the POA must be reported as either 1 or left blank. 
 We looked at the file and Medicare rules. In this case, the diagnosis reported was S32.592D. This diagnosis 
was listed on the POA exempt list for 2020. The POA listed on the claim was Y when it should have been 
marked as Blank or 1. Based on this information, we decided that Medicare rules for coverage of the inpatient 
hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital services provided from May 5, 2020, through May 21, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 
services are not medically necessary. Our physician reviewer found you do not have documented skilled 
nursing needs or skilled therapy needs. You appear unable to participate in daily skilled therapy. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of your 
condition. Your care needs, as a practical matter, can be provided at a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Boost nutritional supplements. 
 
You asked the Plan to pre-approve these services. You say that your doctor recommended the supplements. 
The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Boost nutritional supplements.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-transport ambulance services you received on January 2, 
2022. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that the paramedics determined 
that you did not need to be transported, so this should be paid. The Plan denied your request. The Plan says 
non-transport ambulance services are not covered. 
 
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 January 2, 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 non-transport ambulance services you received on 
January 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5299) provided December 27, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that the provider did not correctly advise you of what 
hearing aids were covered. The Plan denied your request. The Plan says this type of hearing aid is not covered 
under your benefits. 
 
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 when you see one of the Plans hearing providers and purchase one of the hearing aid types 
listed in the Plans EOC. 
 
We looked at the file and the Plan's rules. In this case the hearing aid type purchased is not one of the types 
covered under your benefits. Therefore, we decided that the Plan does not have to pay for the hearing aids 
(V5299) provided December 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for services you received from a Licensed Marriage and Family 
Therapist (LMFT) on February 1, 2022. 
 
You asked the Plan to pay for the LMFT services. You say that you believe this provider is eligible. The Plan 
denied your request. The Plan says the services were received from an ineligible provider. 
 
The Plan must follow Medicare rules. Medicare rules say that the only provider types eligible to provide 
Medicare-covered mental health services are as follows: Physicians, Clinical Psychologists, Clinical Social 
Workers, Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants, Certified Nurse-Midwives, 
Independently Practicing Psychologists, and Certified Registered Nurse Anesthetists.  Licensed Marriage and 
Family Therapists are not eligible for Medicare coverage. Therefore, we decided that the Plan does not have to 
pay for services you received from a Licensed Marriage and Family Therapist (LMFT) on February 1, 2022.