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

 
We decided that the Plan does not have to pay for the power scooter (E1399), provided on May 24, 2022. 
 
You asked the Plan to pay for the power scooter. You say that the item was medically necessary. The Plan 
denied your request. The Plan says there was no physician signed seven element order, face to face 
examination with your provider, physician signed detailed product description order, physical/occupational 
therapy assessment, or home assessment provided. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs and your 
condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pay for the power 
scooter (E1399), provided on May 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 7, 2020. 
 
You asked the Plan to pay for the lab services. You say that it was not the provider's fault that this claim was 
not submitted on time. The Plan denied your request. The Plan says this claim was not filed timely. 
 
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 the lab services was not filed until May 20, 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 the lab services provided on July 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examination, corneal pachymetry, and 
ophthalmic diagnostic imaging provided on September 23, 2022, by an OON provider. 
 
You asked the Plan to pay for the examination, pachymetry, and imaging. You say that these procedures were 
part of your annual eye exam. You also say that you thought the provider checked with the Plan beforehand to 
make sure that the services were covered. The Plan denied your request. The Plan says that the denied services 
were not authorized to be provided by an out-of-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 a visual field examination, corneal pachymetry, 
and ophthalmic diagnostic imaging provided on September 23, 2022, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device and related supplies 
provided on August 26, 2022. 
 
You asked the Plan to pay for the billed services. You say that the equipment was issued for use during 
surgery. The Plan denied your request. The Plan says Medicare does not consider an outpatient hospital a 
home. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
 
 The items at issue in this appeal were for use at an outpatient hospital facility. Although the items may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pay for the pneumatic compression device and related supplies provided on August 
26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0150, D0274 and D0603) on October 
26, 2022. 
 
You asked the Plan to pay for the dental services (D0150, D0274 and D0603). You say that you would like to 
request reconsideration of the denied claim. The Plan denied your request. The Plan says your benefit for the 
requested dental services (D0150 and D0274) has already been exhausted. The dental service (D0603) is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 09, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0150, D0274 and D0603) on 
October 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF stay provided from April 27, 2022, to 
May 27, 2022. 
 
You asked the Plan to waive the copayment for SNF stay. You say that you are on a fixed income and cannot 
afford to pay the copayment. 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 $0 
copayment per day for days 1-20 for each stay and $188 copayment per day for days 21-100 for each stay. 
 
  You have been asked to pay $1,780, which is less than the standard $1,880 for SNF stay. The standard amount 
is $188/per visit x 10/days = $1,880. The SNF stay falls within the skilled nursing facility (SNF) 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 SNF stay provided from April 27, 2022, to May 
27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and drugs dispensed in the office 
(D9630) provided on October 21, 2022. 
 
You asked the Plan to pay for gingival irrigation and drugs dispensed in the office. You say that you were not 
told of any stipulations for your dental coverage. The Plan denied your request. The Plan says gingival 
irrigation (D4921) and drugs dispensed in the office (D9630) are not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for gingival 
irrigation (D4921) and drugs dispensed in the office (D9630) provided on October 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression devices (E0673 and E0675), 
provided on August 16, 2022. 
 
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered by 
Medicare when the place of service is an ambulatory surgical center. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the pneumatic compression devices were used in an ambulatory surgical center. Therefore, 
we decided that the Plan does not have to pay for the pneumatic compression devices (E0673 and E0675), 
provided on August 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).

You asked the Plan to pre-approve a portable oxygen concentrator. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.

The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from such factors as the patient's age, the patient's skin pigmentation, the altitude level, or the patient's decreased oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not have a non-covered indication.

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 portable oxygen concentrator Our reviewer says that the item is not medically necessary. Our physician reviewer found the records do not include documentation that you are able to maintain a PaO2 of at least 91% during activity using an oxygen conserving device at a flow rate of 1 to 4 L/min.

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 portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
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 not medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is medically 
necessary. 
 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 the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you cannot be left alone as you are unable to do daily 
activities on your own, and you need to go to rehab. The Plan denied your request. The Plan says an IRF 
admission is not medically necessary, and your needs can be provided safely in other settings. 
 
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 you do not meet criteria for admission to an acute inpatient rehabilitation facility. 
The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. You can receive further services 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Special Supplemental Benefits for Chronically Ill 
(SSBCI) benefit. 
 
You asked the Plan to pre-approve SSBCI benefit. You say that you need the extra assistance due to your 
diagnosis. The Plan denied your request. The Plan says the criteria for this benefit have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees who require intensive care management.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefit have not been met. Specifically, the file does not indicate that you require intensive 
care management. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental 
Benefits for Chronically Ill (SSBCI) benefit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on May 18, 2021, to 
May 20, 2021 at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that you are 
requesting reconsideration as you do not believe an overpayment has been made in this case. The Plan denied 
your request. The Plan says the medical records do not support diagnosis code N17.9 with DRG 683. 
 
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 diagnosis code N17.9, defined as acute kidney 
failure, unspecified. 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 inpatient hospital 
services at the DRG originally billed. Our reviewer says that the documentation does not support diagnosis 
code N17.9. Our physician reviewer found there was no clinical or laboratory evidence of acute kidney failure. 
 
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 on May 18, 2021, to May 20, 2021 at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says the requested IRF services do not meet the requirements for approval. 
 
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 clinical documentation shows active medical comorbidities. However, no 
complex functional impairments (IRF compliant or complex rehabilitation diagnosis) are specified, thus the complexity of the enrollee's documented nursing, medical, and rehabilitation needs would not be expected to 
require an IRF stay. Our reviewer found that IRF criteria are not met. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six visits with an out-of-network (OON) 
otolaryngologist (ENT). 
 You asked the Plan to pre-approve six visits with OON ENT. You say that the requested provider specializes in 
sleep apnea issues that may require surgery. You say that regular ENT departments do not treat patients for 
sleep apnea. You say that you confirmed this with these offices. You also say that is why your doctor referred 
you to this office. The Plan denied your request. The Plan says you have not had an initial evaluation by an 
ENT. The Plan also says that there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of six visits with OON ENT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve six visits with an out-of-network (OON) otolaryngologist (ENT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
September 14, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service September 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraorifice barrier (D3911), treatment of root canal 
obstruction (D3331), and preventive procedure (D1999) provided on October 25, 2022. 
 
You asked the Plan to pay for the intraorifice barrier, treatment of root canal obstruction, and preventive 
procedure. You say that you still need two more root canals, and have not been able to do it because the Plan 
does not want to pay for the treatment. The Plan denied your request. The Plan says these services are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraorifice barrier (D3911), treatment of root canal obstruction (D3331), and preventive procedure (D1999) 
provided on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761), provided on October 24, 2022. 
 
You asked the Plan to pay for the elbow orthosis. You say that the item should be covered. 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. Your 
contract with the Plan says that there is a $1,500 deductible which applies to prosthetic devices and related 
supplies.  
 
The item or service you asked the Plan to pay for falls within the prosthetic devices and related supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,500 
deductible which applies to prosthetic devices and related supplies. This cost sharing is a contractual obligation 
that had not been met at the time the elbow orthosis was received on October 24, 2022. Therefore, we decided 
that the Plan does not have to pay for the elbow orthosis (L3761), provided on October 24, 2022.