Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the fitness class provided on July 6, 2022. 
 
You asked the Plan to pay for the fitness class. You say that you have been reimbursed for this exact fitness 
class in the past, and would like this denial to be overturned. The Plan denied your request. The Plan says that 
this claim was denied appropriately. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only for memberships at a qualifying fitness facility. 
 
The Plans rules for coverage of gym benefits have been met because physical therapy centers are not listed as 
an excluded facility under the fitness facility benefit. The Plan contract also does not seem to clearly list every 
type of qualifying fitness facility that would be covered, but only lists some included facilities that qualify 
under your benefit. You reasonably believed this service would be covered. Therefore, we decided that the Plan 
has to pay for the fitness class provided on July 6, 2022.  
 
 
 
 
 
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve strawberry ensure nutritional drink. 
 
You asked the Plan to pre-approve strawberry ensure nutritional drink. You say that that due to medical issues 
you have lost a significant amount of weight and you are trying to gain it back. You say that you can only 
sometimes eat regular foods however your health issues only allow you to eat enough to stay alive. You say 
that you had strawberry ensure nutritional drink at the hospital, and you liked it and are hoping this could be 
something that can be covered by the Plan. The Plan denied your request. The Plan says this nutritional drink is 
excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve strawberry ensure nutritional drink.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for Physical therapy visits provided from June 
6, 2022, to June 21, 2022.  
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you cannot afford these 
copayments, and that you are on a fixed income. The Plan denied your request. The Plan says this cost sharing 
was charged 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 $40 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay an $80 total copayment for two physical therapy visits ($40 x 2 = $80). This 
item/service falls within the outpatient rehabilitation 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 copayments for Physical therapy visits provided from June 6, 2022, to June 21, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the SNF services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they are 
non-emergent and can be provided 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 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 
SNF services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs the therapy and physician 
oversight that they can only get at an IRF. The Plan denied your request. The Plan says admission to the IRF 
does not meet the Medicare guidelines and the enrollee can receive the services they need in another setting 
like a skilled nursing facility. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee was admitted for dizziness, falls, urinary tract infection, and 
congestive heart failure. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical 
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically 
necessary care can be provided in a different level of care. 
 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 5, 2022 billed with 
codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, & 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 5, 2022 billed with codes 81201, 81292, 81295, 81298, 81314, 81317, 81334, 81351, & 81479.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation for the third quarter of 
2022. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need transportation for 
all of your medical appointments. The Plan denied your request. The Plan says you have exhausted your 
transportation benefit. The Plan says that in the quarter, you received your 6 covered transports on July 20, 
2022 (two trips per date), August 9, 2022, (two trips per date), and September 15, 2022 (two trips per date.) 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 6 trips per quarter.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation for the third quarter 
of the year.  You may request transports under your 6 allowed trips in the fourth quarter of the year. Therefore, 
we decided that the Plan does not have to pre-approve additional routine transportation for the third quarter of 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for an outpatient hospital visit on June 6, 
2022. 
 
You asked the Plan to reduce the copayment for an outpatient hospital visit. You say that you should only be 
responsible to pay $25. The Plan denied your request. The Plan says this cost sharing was charged 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 $250 
copayment for in-network Medicare-covered outpatient hospital services.  
 
 
 
 
 
 
 You have been asked to pay $117.53 for an outpatient hospital visit, which is less than the standard $250 
copayment. This item/service falls 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 reduce the copayment for an outpatient hospital visit on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical assistant services provided by a Registered Nurse 
First Assistant (RNFA) on March 7, 2022. 
 
You asked the Plan to pay for the RNFA services. You say that this was the only assistant available so the 
services should be covered. The Plan denied your request. The Plan says the assistant billing for these services 
is an ineligible provider for Medicare. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided 
by a Registered Nurse First Assistant (RNFA) on March 7, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 28, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that these services were medically appropriate 
and provided on an emergency basis. The Plan denied your request. The Plan says the corrected claim you 
submitted contains errors. 
 
The Plan must follow Medicare rules. Medicare rules say that providers should submit adjusted claims to 
correct simple errors with initial claims. It appears as though you did attempt to submit a corrected claim in this 
case.  However, for the second claim you submitted as a replacement for the original claim, you erroneously 
submitted information for another patient with another name, another date of service, and a completely 
different billed amount.  In other words, this was not a 'corrected claim' of the original claim, making it not 
processable. The Plan did not deny payment on this claim based on medical necessity, but denied it based on 
this erroneous corrected claim. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to 
pay for ambulance services provided on December 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that the patient requires full mouth 
extractions in an area where they have already received radiation and hyperbaric oxygen therapy can prevent 
osteoradionecrosis. The Plan denied your request. The Plan says hyperbaric oxygen therapy is not covered for 
prevention of osteoradionecrosis. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers hyperbaric oxygen therapy only 
for the following conditions: acute carbon monoxide intoxication, decompression illness, gas embolism, gas 
gangrene, acute traumatic peripheral ischemia, crush injuries and suturing of severed limbs, progressive 
necrotizing infections, acute peripheral arterial insufficiency, preparation of skin grafts, chronic refractory 
osteomyelitis, osteoradionecrosis, soft tissue radionecrosis, cyanide poisoning, actinomycosis, and certain 
diabetic wounds of the lower extremities. All other indications are non-covered.  The prevention of 
osteoradionecrosis is not listed as a covered indication, regardless of appropriateness. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tub stool or bench (E0245). 
 
You asked the Plan to pre-approve a tub stool or bench. You say that you cannot maintain your balance. You 
are constantly falling backwards and sideways. The Plan denied your request. The Plan says the item requested 
is not covered, as it is considered a convenience item and not primarily medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a tub stool or bench (E0245).
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 you need SNF care to work on balance, strength and 
stamina. The Plan denied your request. The Plan says criteria for admission to SNF have not been met. Skilled 
services can be provided on an intermittent outpatient basis, in a long-term care facility, or at the home with 
home health care services. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for diabetic supplies provided on February 3, 
2022. 
 
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you were not informed of the 
coinsurance for this item. You feel you should not be charged for this coinsurance. The Plan denied your 
request. The Plan says this cost sharing was charged 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 20% 
coinsurance for durable medical equipment (DME). The allowed amount of this item or service was $77.70, 
resulting in a coinsurance of $15.54 ($77.70 x 20% = $15.54). 
 
You have been asked to pay a $15.54 coinsurance for diabetic supplies. This item/service falls within the 
durable medical equipment (DME) 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 
diabetic supplies provided on February 3, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. Your medical 
needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested LTACH services are not medically necessary, reasonable, and 
appropriate for your diagnosis and condition and you are able to be furnished safely and effectively only on an 
inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient services provided on March 
29th, 2022, to April 10th, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that this bill is very confusing 
and questionable. The Plan denied your request. The Plan says this cost sharing was charged 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 $260 
copayment per day for days 1 to 8 for inpatient hospital care. This inpatient hospital stay lasted 12 days, 
resulting in a copayment amount of $2,080 ($260 per day for 8 days = $2,080). 
 
You have been asked to pay $260 copayment per day for days 1 to 8 for inpatient hospital care. This 
item/service 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 the inpatient services provided on March 29th, 2022, to April 10th, 2022.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for medical services provided on May 5, 2022. 
 
You asked the Plan to pay for the medical services. You say that this service was billed correctly and should be 
paid. The Plan denied your request. The Plan says that you billed with both a left and a right diagnosis for 
carpal tunnel syndrome when you should have billed with a bilateral diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan's sole rationale for denial is that instead of billing the left 
and the right diagnosis codes for carpal tunnel syndrome (i.e., G56.01 and G56.02), you should have billed the 
diagnosis code for bilateral carpal tunnel syndrome (G56.03).  We do not find the Plan's argument appropriate 
here.  According to the American ICD-10 coding data, the bilateral diagnosis code of G56.03 did not become 
effective until October 1, 2022 (see the 2023 edition of ICD-10-CM).  The services in dispute occurred prior to 
the effective date of this bilateral diagnosis code, so it would have been inappropriate to use this code for 
services prior to October 1, 2022.  The Plan has offered no other rationales for the denial of this claim. 
Therefore, we decided that the Plan has to pay for medical services provided on May 5, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.