Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from February 5, 2020, through  
April 26, 2020. 
 
You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the claims were 
received beyond the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claims for SNF services was not filed until November 4, 2021. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for skilled nursing facility (SNF) services provided from February 5, 2020, 
through April 26, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the emergency ambulance transportation (A0427) and ground mileage 
(A0425) provided on November 22, 2021. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. The Plan denied 
your request. The Plan says that the information provided does not support medical necessity for this 
ambulance transport. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules.  
 
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 emergency ambulance transportation and ground mileage. Our reviewer says that transportation 
by ambulance to the emergency department was medically necessary. Our physician reviewer found the 
enrollee did require the expertise of trained personnel or the equipment available only on an ambulance in order 
to effectuate a safe transport. Our reviewer found that transportation could not have been provided by other 
means (stretcher van, wheelchair van, private car, taxi) without endangering the enrollees condition. Our 
physician reviewer also found that a prudent layperson would believe that immediate medical attention was 
required for someone who claimed their legs did not work. 
 
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 emergency ambulance transportation and ground mileage have been met. 
Therefore, we decided that the Plan has to pay for the emergency ambulance transportation (A0427) and 
ground mileage (A0425) provided on November 22, 2021.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endoscopy and related services provided on September 
20, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that services were provided in good faith. The Plan 
denied your request. The Plan says the services were not urgent, emergent, or 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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 endoscopy and related services provided on September 20, 2021, by an out-
of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered 
by Medicare due to insufficient evidence of efficacy. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The vertiflex device 
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and hearing tests provided on December 2, 
2020. 
 
You asked the Plan to pay for the office visit and hearing tests. You say that you do not have the resources to 
pay and ask for these bills to be paid. The Plan denied your request. The Plan says the corrected claim was not 
received within the 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that the corrected claim for the office visit and hearing tests was not filed until January 26, 
2022. This means that more than one calendar year from the date of service had passed before a claim was 
filed. You are not responsible for any amount billed on this corrected claim Therefore, we decided that the Plan 
does not have to pay for the office visit and hearing tests provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious agent detection provided on August 5, 2021. 
 
You asked the Plan to pay for the infectious agent detection services. You say that this testing was medically 
necessary. The Plan denied your request. The Plan says this was not billed with the appropriate POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious agent detection services have not been met. Specifically, this claim was billed with 
the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. 
Therefore, we decided that the Plan does not have to pay for the infectious agent detection provided on August 
5, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for fitness equipment purchased on October 15, 2021. 
 
You asked the Plan to pay for the services. You say that you were told that you could purchase this item, and 
were not told that it had to be through a retail store. The Plan denied your request. The Plan says that fitness 
equipment must be purchased from a retail store. 
 
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. The plan has not substantiated their denial. The Evidence of Coverage does not 
specify that fitness equipment must be purchased through any specific stores. It appears that you were not told 
that you could not purchase the kayak through Facebook Marketplace. Therefore, we decided that the Plan has 
to pay for fitness equipment purchased on October 15, 2021.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction provided on June 29, 2021. 
 
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says the eye refraction 
is not a covered benefit since it was medical vision check (Age-related nuclear cataract, Bilateral). 
 
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye 
exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in 
connection with otherwise covered diagnosis or treatment of illness or injury. 
 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of 
any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when 
done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided 
that the Plan does not have to pay for an eye refraction provided on June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on July 27, 
2021. 
 
You asked the Plan to pay for the services. You say that the rendered services meet professionally recognized 
standards of healthcare. The Plan denied your request. The Plan says the provider must attempt to consult the 
attending or primary care physician about the services furnished and document the consent or declination date 
to consultations, and the date of consultations in the patients medical record. 
 The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, the record does not include documentation of a 
consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. 
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided to the enrollee on 
July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infectious agent detection (87482, 87798, 87799) provided 
on December 7, 2021. 
 
You asked the Plan to pay for infectious agent detection. You say that this testing is supported in the records. 
The Plan denied your request. The Plan says this was not medically necessary. 
 The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must 
be related to a patients illness or injury (or symptom or complaint). The rules also say that the provider, 
supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to 
determine whether payment is due and the amount of payment. 
 
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 infectious agent detection (87482, 
87798, 87799) provided on December 7, 2021. have been met. The records submitted do not indicate that this 
testing was related to the patients illness or injury. Of note, the submitted office visit records are for a date 
several months before this testing was ordered and do not document related symptoms or illness. Therefore, we 
decided that the Plan does not have to pay for infectious agent detection (87482, 87798, 87799) provided on 
December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee will be unable to walk 
up and down the stairs after their upcoming surgery. The Plan denied your request. The Plan says that there is 
no mention the enrollee needs a hospital bed due to a medical problem. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 a semi-electric hospital bed. Our 
reviewer says that a semi-electric hospital bed is not medically reasonable and necessary. There is no 
documentation that the patient's condition requires position of the body in ways not feasible in an ordinary bed. 
There is no documentation that the patient's condition requires frequent changes in body position or immediate 
changes in body position. There is no documentation that the patient's condition requires special attachments 
that cannot be fixed and used on an ordinary bed. Our physician reviewer found that the enrollee's condition 
does not meet Medicare criteria for a semi-electric hospital bed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid, digital, binaural, behind the ear (V5261) 
provided January 26, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you expect a portion of the annual hearing aid 
allowance to be reimbursed to you. The Plan denied your request. The Plan says there is no reimbursement 
offered for hearing aids that are not purchased from the Plans specified hearing aid provider. 
 
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 purchased from the Plans specified hearing aid provider. 
 
We looked at the file and the Plan's rules. In this case the hearing aids were not provided by a specified hearing 
aid provider as specified in the Plans EOC. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aid, digital, binaural, behind the ear (V5261) provided January 26, 2021.  
 Your complaint about your frustrations with the Plans customer service and speed of the appeal process is not 
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on October 9, 
2021. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular genetic testing provided on October 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory testing provided on October 8, 2021. 
 
You asked the Plan to pay for the lab testing. You say that these are separately payable services. The Plan 
denied your request. The Plan says lab testing for an ESRD patient is paid through the composite rate to the 
ESRD facility. 
 
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 laboratory testing provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services medical examination and 
evaluation provided on November 29, 2021. 
 
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. The Plan denied 
your request. The Plan says authorization was not obtained prior to the services being rendered and the 
provider is not participating with the member's plan. 
 
 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 
services 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 ophthalmological services medical examination and evaluation 
provided on November 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
4, 2021, to May 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported inpatient hospital services with the incorrect DRG.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS 
WITHOUT MV >96 HOURS WITH MCC). 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 
services. Our reviewer says that the services at issue in this case were not supported by the medical records. 
Our physician reviewer found the enrollee was admitted and treated in the hospital for urinary retention, 
urinary tract infection, and pyelonephrosis complicated by pulmonary embolism. Sepsis was not supported as a 
diagnosis for this admission as the patient did not meet Sepsis 3 criteria for such. Vitals were relatively stable 
and she was neurologically stable. There was no clear signs of life-threatening organ dysfunction as a result of 
a dysregulated systemic reaction to the patient's infection. Therefore, the documentation best supports the DRG 
689 and not DRG 871.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided to the enrollee from May 4, 2021, to May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on October 11, 2021. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says that chiropractic 
services are limited to spinal manipulation. In addition, this provider is not contracted with the Plan. 
 
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. Medicare rules also say that the only chiropractic service 
Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the file, the Medicare rules and the Plans rules. The requested provider in this case is not a 
network provider with the Plan. The Plan did not pre-approve the services at issue. Additionally, the only 
chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 an office visit provided on October 11, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are in-network providers available for home health care. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home health services to be provided by an out-of-network (OON) provider.