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

 
We decided that the Plan does not have to pay for the physician services provided on January 13, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
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 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 physician services provided on January 13, 
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 a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical records from the provider state that the enrollee had a trial of the basic pump, 
but no objective measurements are provided. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that a reasonable trial with the basic pump had been tried prior to ordering the 
segmented pump. The enrollee was contacted directly on 4/29/2022 and states she has never used a pump on 
her legs. The review has determined that the enrollee does not have lymphedema of the chest, trunk, or 
abdomen. The enrollee does not have unique characteristics that would indicate the segmented pump over a 
standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on  
October 17, 2020. 
 
You asked the Plan to pay for an emergency department visit. The Plan denied your request. The Plan says the 
claim was untimely and the submission did not meet the exception criteria guidelines outlined in Medicare. 
 
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 claim for an emergency department visit was not filed until January 27, 2022. 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 an emergency department visit provided on 
October 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction (92015) provided on December 10, 2021. 
 
You asked the Plan to pay for the eye refraction. You say that this service was necessary and has been covered 
for you before. The Plan denied your request. The Plan says the eye refraction in this case was provided with a medical eye exam. You do have a supplemental benefit which covers one eye refraction per year; however, this 
refraction must be provided as part of a routine (non-medical) eye exam which is provided to detect changes in 
vision for the purpose of an eyewear prescription. Refractions are not covered in conjunction with medical eye 
exams. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services only when they are provided as part of a routine (non-medical) eye 
exam. 
 
We looked at the file and the Plan's rules. The documentation in this case supports that this eye refraction was 
provided with a medical eye exam. Based on this information, we decided that the Plan's rules for coverage of 
the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye 
refraction (92015) provided on December 10, 2021.
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 requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs or documented skilled therapy needs. The enrollee appears unable to participate in the rigors of 
daily skilled therapy. Daily skilled services are not required to establish a maintenance program or to prevent 
deterioration of the enrollees condition.  The enrollees care needs, custodial and intermittent, can, as a 
practical matter, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unilateral radiofrequency ablation (RFA) of the facet 
joint nerves at three spinal levels. 
 
You asked the Plan to pre-approve the three-level facet joint RFA procedure. You say that it is felt that this 
should be approved to help with the enrollee's axial low back pain. The Plan denied your request. The Plan says 
more than two levels cannot be covered. 
 
The Plan follows Medicare rules. Medicare rules say that RFA treatment of one or two levels is considered 
reasonable and necessary. For additional levels, unique circumstances must be present to justify the medical 
necessity.  
 
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 three-level facet joint RFA 
procedure. Our reviewer says that the requested three-level procedure is not considered reasonable and 
necessary. Our physician reviewer found the enrollee has chronic low back pain. She has tried physical therapy 
and is doing a Home Exercise Program. She had 2 sets of diagnostic MBBs L2-L4 which produced 100% pain relief.  
 
Only 2 levels bilaterally are deemed medically reasonable and necessary. The third level exceeds utilization 
guidelines. There is a lack of support that there are unique circumstances which make additional levels in the 
same session medically reasonable and 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 three-level facet joint RFA procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve unilateral radiofrequency ablation (RFA) of the facet joint 
nerves at three spinal levels.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 11, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that your group was not included in the subset of 
physicians chosen to participate in this Plan. The Plan denied your request. The Plan says this provider is not a 
network provider with the Plan and based on the documentation submitted, you have determined that the 
services rendered to the member are not urgent or emergent, nor were they approved in advance by a network 
provider. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 11, 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 Outpatient Hospital services provided on January 25, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Outpatient Hospital services. 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 were 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 Outpatient Hospital 
services provided on January 25, 2022 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient audiology services provided on 
July 9, 2021, and August 3, 2021. 
 
You asked the Plan to waive the copayment for outpatient audiology services. You say that you already paid 
$40 in copayments at the time of service. The Plan denied your request. The Plan says the copayment was 
applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for in-network diagnostic procedures and tests conducted at an outpatient hospital.  
 
 You have been asked to pay a total of $180 for the outpatient audiology services. Audiology services fall 
within the Outpatient hospital 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 outpatient audiology services provided on July 9, 2021, and August 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve myocardial imaging with positron emission tomography 
(PET) for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically 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 the imaging. Our reviewer says that the 
requested imaging is not medically reasonable or necessary. Our physician reviewer found the previous PET 
scan in April 2021 already demonstrated a reversible myocardial defect. The guidelines do not support the use 
of repeat cardiac PET imaging in this role. As a result, at this time cardiac PET scanning would not be 
considered medically reasonable and necessary in this patient's clinical management. 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve myocardial imaging with positron emission tomography (PET) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for injection provided by The Wheelchair 
Store on January 6, 2022. 
 
You asked the Plan to waive the copayment for injection. You say that you do not believe that you should have 
received a bill for $734.35. The Plan denied your request. The Plan says the 20% coinsurance you are being 
charged 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 20% 
coinsurance for injection. The allowed amount of this injection is $3,671.75, resulting in a coinsurance amount 
of $734.35. 
 
You have been asked to pay 20% coinsurance for injection. injection falls within the injection 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 injection provided by The 
Wheelchair Store on January 6, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for portable liquid oxygen system, purchase; includes portable 
container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor 
(E0435) purchased on July 14, 2021. 
 
You asked the Plan to pay for the portable liquid oxygen system. You say that you had talked with Medicare in 
November and they said the Onigen portable oxygen unit is covered by Medicare and Advantage programs. 
The Plan denied your request. The Plan says Medicare does not cover for the purchase of oxygen equipment. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
In this case, you are requesting reimbursement for the purchase of oxygen equipment. The contract specifically 
says that the Plan will cover for the rental of oxygen equipment. Medicare does not cover for the purchase of 
oxygen equipment. Therefore, the Plan does not cover for the purchase of oxygen equipment. Based on this 
information, we decided that Medicare rules for coverage of the portable liquid oxygen system have not been 
met. Therefore, we decided that the Plan does not have to pay for portable liquid oxygen system, purchase; 
includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing 
and refill adaptor (E0435) purchased on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health care services provided from March 25, 
2021, to April 23, 2021. 
 
You asked the Plan to pay for the home health care services. You say that you would like approval and 
payment to be reconsidered for the home health services that were provided. The Plan denied your request. The 
Plan says the non-contracted provider did not submit the RAP claim for services for dates of service March 25, 
2021, to April 23, 2021 until July 15, 2021. The Plan also says that no exception request was submitted to the 
Health Plan to waive the 5-day requirement for filing the RAP claim due to a circumstance beyond the 
provider's control. 
 
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit 
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day 
periods and within 5 calendar days after the from date for each subsequent 30-day period of care, which is set 
at 0 percent at the beginning of every 30-day period.  
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health care services have not been met. Specifically, the record indicates the RAP was 
not submitted within 5 days of the from the start of care date. Therefore, we decided that the Plan does not have 
to pay for the home health care services provided from March 25, 2021, to April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found the enrollee has complex medical, nursing and rehabilitation needs documented that warrant inpatient 
rehabilitation in acute care stay that focuses on rehabilitation. The enrollee has documented complex medical 
conditions that would warrant at least 3 physician visits per week and consult services that would not otherwise 
be available. Evaluating therapist specifically documents the enrollee's ability to benefit from and tolerate 
intense rehabilitation of 3hrs per day, 5 days per week in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging (MRI), upper 
extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences 
(CPT code 73220). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. 
The Plan says they do not have an x-ray taken after a change in the enrollee's symptoms that show a need for 
further imaging. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 the MRI. Our physician reviewer found 
there is no specific clinical rationale for the requested MRI. The review has determined that the requested MRI 
is not medically reasonable or 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 MRI have not been met. 
 
 
  Therefore, we decided that the Plan does not have to pre-approve magnetic resonance (eg, proton) imaging 
(MRI), upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and 
further sequences (CPT code 73220).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has had an increase in pain that is 
affecting their ability to walk without pain. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics.