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

 
We decided that the Plan does not have to waive the coinsurance for a nebulizer with compressor provided on 
February 20, 2021. 
 
You asked the Plan to waive the coinsurance for the nebulizer. You say that you were not aware of the monthly 
charges and cannot afford them. 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 durable medical equipment (DME) items, including oxygen equipment.  You have been asked to pay $1.75, which is 20% of the allowed amount for the nebulizer ($8.74 allowed 
amount x 20% coinsurance = $1.75). The nebulizer falls 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 a nebulizer with 
compressor provided on February 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found You have osteoarthritis in both knees. 
The records do not show that you have tried and failed conservative treatments, such as physical therapy and 
simple pain medication. The Food and Drug Administration (FDA) has not stated that the requested drug is 
indicated for your condition. The Euflexxa is therefore not reasonable or medically necessary. 
 
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 Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a safety belt, rear frame, and pneumatic airless tires for 
an ultralight wheelchair. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the safety belt is included in the 
approved wheelchair and would therefore be a duplicate item. The records do not reveal extenuating factors that indicate the enrollee requires pneumatic tires over standard tires. Pneumatic airless tires exceed the 
enrollee's functional and medical need. The rear frame K0108 exceeds the enrollee's medical and functional 
needs as his needs can be met with the frame on the approved wheelchair. 
 
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 a safety belt, rear frame, and pneumatic airless tires for an ultralight wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis treatment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the dialysis treatment. You say that the services should be covered as you 
disagree with the denial and would like to continue seeing the out-of-network provider. The Plan denied your 
request. The Plan says the services denied correctly as there are in-network providers who can provide the 
same services and are closer to you. 
 
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 
dialysis treatment to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect place of 
service on the claim. 
 
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 lab 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 lab services provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee orthosis (L1851) for both knees 
 
You asked the Plan to pre-approve the orthosis. You say that the attached medical records shows that CPT 
L1851 for both knees is medically necessary. Please approve your denied authorization. The Plan denied your 
request. The Plan says the request is not medically necessary because the records do not show recent injury or 
surgery or evidence of instability. 
 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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, the member has not had recent surgery or a recent injury. The documentation 
doesnt support that the joint is unstable or that there is joint laxity. The requested knee orthosis is not 
medically necessary. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the knee orthosis (L1851) for both knees
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494) 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 your request is not medically necessary because records show the 
enrollee does not have an absence of non-facet pathology as the enrollee has diagnoses of spinal stenosis, 
degenerative discs, and radiculopathy documented in the medical record. 
 
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 records show the 
enrollee has radiculopathy and does not have an absence of non-facet pathology as she has diagnoses of spinal 
stenosis, and degenerative discs. 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 facet joint injections (64493, 64494) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at home COVID-19 tests purchased on April 25, 2022. 
 
You asked the Plan to pay for the at home COVID-19 tests. You say that you were told the Plan is responsible 
for reimbursing you. The Plan denied your request. The Plan says the Plan's coverage makes no mention of 
covering at home COVID-19 testing. The Plan also says that you did not contact the Plan prior to the purchase 
date to verify coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for over-the-counter (OTC) 
items and the at home COVID-19 tests are an OTC item. The Plan does not offer a supplemental benefit 
covering this service, as this is not currently required by Medicare. However, for future purchases, these can be 
obtained with participating providers and covered by Original Medicare when using your Medicare card rather 
than your Plan card. Neither Medicare nor your Plan currently offers reimbursement of purchased COVID-19 
tests. Therefore, we decided that the Plan does not have to pay for the at home COVID-19 tests purchased on April 
25, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot go up the stairs at home. You do not feel 
you should be at home. The Plan denied your request. The Plan says your level of function is very high, does 
not meet SNF care guidelines. 
 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 SNF 
care is not medically reasonable and necessary. Our physician reviewer found that you do not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You 
do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. You do 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 a skilled nursing facility (SNF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta 32mg injections for both knees. 
 
You asked the Plan to pre-approve Zilretta 32mg injections for both knees. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Zilretta 32mg injections for both knees. 
Our reviewer says that the documentation does not support that the requested drug is medically reasonable or 
necessary. Our physician reviewer found you have bilateral osteoarthritis of the knees. You received bilateral 
Zilretta knee injections on February 9, 2022. Based on the medical records provided and the Medicare-
approved major drug compendia there is no documentation that the Zilretta at issue in this case meets Medicare 
criteria for medically reasonable and necessary. The efficacy and safety of repeat administration of Zilretta 
have not been demonstrated. Therefore, you do not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta 32mg injections for both knees have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Zilretta 32mg injections for both knees.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that the provider you want to see has a track record 
of excellence and the other doctor failed to notice the test. The Plan denied your request. The Plan says the 
provider is out-of-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 office visit. We found no exception that would require the Plan to pre-approve 
the office visit. The records provided for review do not show that the office visit is urgent or emergent. 
Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on February 7, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the radiology services. You say that the referring provider sent the enrollee to 
your facility. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the radiology services provided on February 7, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 15, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network, and it was 
determined these services can be received 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 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 February 15, 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 the Group 3 power wheelchair with single power option 
(K0858, E2363, E1028, E0955, E2604, E2310, E1002). 
 You asked the Plan to pre-approve the power wheelchair. You say that please find the attached clinicals and 
documentation to complete a reconsideration for the enrollee. The Plan denied your request. The Plan says the 
enrollee does not have a qualifying diagnosis and does not meet the criteria for a group 3 power wheelchair 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
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 power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a mobility deficit that impairs MRADLs in the home. The 
documentation notes that she cannot stand therefore cannot use a cane/walker. She has UE weakness and 
morbid obesity and cannot use a manual wheelchair. The documentation does not reveal that the enrollee has a 
Group 3 qualifying diagnosis of a neurological condition, myopathy or congenital skeletal deformity which is 
causing mobility impairment. She does not require power tilt as she has no intermittent catheterization, is not at 
high risk of a pressure ulcer, and no spasticity. The requested wheelchair with power tilt exceeds the patient's 
medical needs. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Group 3 power wheelchair with single power option (K0858, E2363, E1028, 
E0955, E2604, E2310, E1002).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from April 14, 2020, to 
May 19, 2021. 
 
You asked the Plan to pay for the psychotherapy. The Plan denied your request. The Plan says the services 
were provided by a provider who chose not to receive Medicare funds. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
psychotherapy provided from April 14, 2020, to May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services and diagnostic testing services provided 
on January 28, 2022, to March 3, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for physician services and diagnostic testing services. You say that you were 
referred to the out-of-network providers by your in-network primary care physician. You say you went in with 
full confidence that these bills would be covered. The Plan denied your request. The Plan says the providers 
were out-of-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 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 
physician services and diagnostic testing services. We found no exception that would require the Plan to pay 
for the physician services and diagnostic testing services. The records provided for review do not show that the 
physician services and diagnostic testing services were urgent or emergent. Therefore, we decided that the Plan does not have to pay for physician services and diagnostic testing services 
provided on January 28, 2022, to March 3, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay provided from 
March 4, 2022, to March 6, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you shouldn't be charged 
for this since you were treated very nicely. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $195 
copayment for each day for days 1 through 7.  
 
You have been asked to pay $390 ($195 x 2 days) copayment for inpatient hospital stay. Inpatient hospital stay 
falls within the Inpatient Hospital Care 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 inpatient hospital stay provided from March 4, 2022, to March 6, 2022.