Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary visit provided on September 4, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary and 
provided in good faith. The Plan denied your request. The Plan says no prior authorization was 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. The requested provider in this case is not a network provider with the Plan. 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 domiciliary visit provided on September 4, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 11, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan 
denied your request. The Plan says no prior authorization was 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.  
The requested provider in this case is not a network provider with the Plan. 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. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the office visit provided on August 11, 2021, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 9, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not request the 
ambulance services and were not aware of the $325 copayment. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
  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 $325 
copayment for ambulance services.  
 
You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on October 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathogen panel testing provided on August 12, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing 
exceeds the enrollee's medical needs. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 We looked at the file and the rules. The medical records do not document a specific clinical indication for the 
testing. There is no specific reason for performing the panel testing clearly documented in the medical records. 
Based on this information, we decided that Medicare rules for coverage of the testing services have not been 
met. Therefore, we decided that the Plan does not have to pay for the pathogen panel testing provided on 
August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a denosumab (Prolia) injection provided 
on November 2, 2021. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you did not have any copayments 
previously. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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% 
coinsurance for Part B drugs.  
 
You have been asked to pay $254.27, which is 20% of the allowed amount for the injection ($1,271.34 allowed 
amount x 20% coinsurance = $254.27). The injection 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 a denosumab (Prolia) injection 
provided on November 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 home health physical therapy visits. 
 
You asked the Plan to pre-approve 8 home health physical therapy visits. 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 home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 8 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has 
determined that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not 
show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to 
improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 home health physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry services rendered on January 7, 2021 to 
November 17, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the charges. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry services 
rendered on January 7, 2021 to November 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an orthovisc injection (J7324) provided on 
August 16, 2021. 
 
You asked the Plan to waive the coinsurance for the orthovisc injection. You say that the services should be 
covered as you were not told the injections would fall under part b. The Plan denied your request. The Plan 
says the coinsurance applied correctly based on the services provided. 
 
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% 
coinsurance for Medicare Part B prescription drugs.  
 
 
  You have been asked to pay a 20% coinsurance for orthovisc injections (allowed is $2,856.53 x 20% = 
$571.31). Orthovisc injections fall 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 an orthovisc injection (J7324) provided on August 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on November 
24, 2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on November 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility services provided on April 14, 2021, 
to June 3, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for skilled nursing facility services. You say that the provider should not be 
penalized for the hospital staff's failure to obtain the proper authorization.  The Plan denied your request. The 
Plan says no prior authorization was 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. 
 
The requested provider in this case is not a network provider with the Plan. 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. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for skilled nursing facility services provided on April 14, 2021, to 
June 3, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Anti-Reflective Coating and Progressive Lenses provided on 
September 13, 2021. 
 You asked the Plan to pay for Anti-Reflective Coating and Progressive Lenses. The Plan denied your request. 
The Plan says the services are excluded from coverage. 
 
Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery 
with insertion of an intraocular lens implant. The Plan contract says covered eyeglasses after cataract surgery 
includes standard frames and lenses.  
 
We looked at the file, the Medicare rules and the Plan's rules. The file shows that the Plan covers Medicare-
covered standard glasses or contacts after each cataract surgery. Anti-Reflective Coating and Progressive 
Lenses are not a covered benefit. Therefore, we decided that the Plan does not have to pay for Anti-Reflective 
Coating and Progressive Lenses provided on September 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you believe that SNF care is needed at this 
time. The Plan denied your request. The Plan says the records show that your needs are custodial in nature, and 
that daily skilled services are not required. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female with a 
medical history of dementia and chronic low back pain who was admitted to an acute hospital due to increased 
confusion. She was diagnosed and treated for a bladder infection and has remained medically stable. The most 
recent therapy documentation indicates the member is at her baseline function. She requires assistance with bed 
mobility and transfers. 
 
The member does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically 
stable and can receive further rehab services at a lower level of care. Although further rehab services would be 
appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a 
lower level of care than a skilled nursing facility.  
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the platelet-rich plasma injections rendered on November 29, 
2021. 
 
You asked the Plan to pay for these services. You say that the doctor recommended the services. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that platelet-rich plasma injections are non-covered. 
 
We looked at the file and Medicare rules. The services at issue are platelet-rich plasma injections. These 
services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the platelet-
rich plasma injections rendered on November 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft for spine surgery for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this allograft's planned usage is not Food and Drug Administration (FDA) approved. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found I factor bone graft is experimental for use in the anterior cervical spine. More research is needed. 
 
 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve allograft for spine surgery for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 21, 2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the charges 
because this is part of your annual wellness exam. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $125 
copayment for diagnostic radiology services.  
 
You have been asked to pay a $125 copayment for an ultrasound. An ultrasound falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an ultrasound provided on July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for foam dressing services (A6212) provided 
on May 7, 2021. 
 
You asked the Plan to waive the coinsurance for the foam dressing services. You say that the services should 
be covered in full. The Plan denied your request. The Plan says the coinsurance applied correctly based on the 
services provided. 
 
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% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
You have been asked to pay a 20% coinsurance for the foam dressing services ($135.60 x 20% = $27.12). 
Foam dressing services fall within the Durable medical equipment (DME) and related 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 coinsurance for foam dressing services (A6212) provided on 
May 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for personal care services, per 15 minutes (T1019) provided 
from September 24, 2020, to September 29, 2020. 
 
You asked the Plan to pay for the personal care services. You say that you were given 3 companies for home 
assistance by the Plan. You also say that these services should be paid. The Plan denied your request. The Plan 
says personal care services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures codes with a Status Code of "I", 
indicating that this code is not valid for Medicare purposes and is not payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, the services in this case have a Status 
Code of "I". Therefore, we decided that the Plan does not have to pay for personal care services, per 15 minutes 
(T1019) provided from September 24, 2020, to September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6531 that 
were issued on June 4, 2021. 
 
You asked the Plan to pay for the compression stockings. You say that the item is medically necessary. The 
Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code 
A6531 that were issued on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on April 12, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that your visit was not paid by your insurance. The Plan 
denied your request. The Plan says no prior authorization was 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. 
 
The requested provider in this case is not a network provider with the Plan. 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 office visit provided on April 12, 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 repair of your power wheelchair. 
 
You asked the Plan to pre-approve the repairs. You say that you are requesting repair of your power wheelchair 
The Plan denied your request. The Plan says Medicare does not cover repairs when the expense for repairs 
exceeds the estimated expense for replacement of the wheelchair. The Plan states the current wheelchair is 
greater than five (5) years old. The Plan states a request for a replacement wheelchair that meets your needs 
and Medicare rules can be reviewed if requested. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the repairs have not been met. Medicare does not cover repairs 
when the expense for repairs exceeds the estimated expense for replacement of the wheelchair. Therefore, we 
decided that the Plan does not have to pre-approve repair of your power wheelchair.