Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from June 6, 2022, to 
June 8, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that you were taken to the emergency room 
after you were in a motor vehicle accident. You also say that it was decided they would do more monitoring 
and evaluation to find the reason behind your chest pain and the cause for fainting. The Plan denied your 
request. The Plan says this claim was processed and denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from June 6, 2022, to June 8, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds criteria for LTACH 
care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The 
enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional 
services. 
 
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 enrollee appears to be more stable and improving and should only require short-
term additional acute care hospital services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for imaging provided on June 28, 2022. 
 
You asked the Plan to waive the copayment for imaging. You say that you cannot afford this charge. 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 $300 
copayment for Diagnostic radiology services. 
 
You have been asked to pay a $300 copayment for imaging. This item/service falls within the Diagnostic 
radiology 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 imaging provided 
on June 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit and services provided on June 27, 2022, by an 
OON provider. 
 
You asked the Plan to pay for an office visit and services. The Plan denied your request. The Plan says the out-
of-network services were not authorized. 
 
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 and services provided on June 27, 
2022, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on June 25, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you cannot 
afford to pay this bill. The Plan denied your request. The Plan says since you were not transported, the services 
are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on June 25, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on June 25, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan has to reimburse you for the Epidurography (72275) provided on January 12, 2022. 
 
You asked the Plan to reimburse you for the Epidurography (72275). You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. Medicare rules also say the Advance Beneficiary Notices (ABNs) proper to the 
FLP provisions are to be used solely for individuals enrolled in the Medicare FFS program and are not to be 
used for Medicare M+C enrollees nor for non-Medicare enrollees. 
 
You were referred for the Epidurography (72275) by a contract provider. The file does not show that the Plan 
provided notice that the Epidurography (72275) would not be covered. Under Medicare rules, this means the 
Epidurography (72275) is considered approved by the Plan. Additionally, Medicare states that ABNs are not 
to be used for Medicare Part C enrollees. Therefore, we decided that the Plan has to reimburse you for the 
Epidurography (72275) provided on January 12, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a coronary artery bypass and surgical endoscopy provided on 
February 10, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a coronary artery bypass and surgical endoscopy. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says the enrollee must receive care from 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 a coronary artery bypass and surgical endoscopy 
provided on February 10, 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 the ophthalmic diagnostic imaging provided on June 30, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the ophthalmic diagnostic imaging. You say that the service was medically 
necessary. The Plan denied your request. The Plan says the provider was 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 
ophthalmic diagnostic imaging. We found no exception that would require the Plan to pay for these the 
ophthalmic diagnostic imaging. The records provided for review do not show that the services at issue were 
urgent or emergent. Therefore, we decided that the Plan does not have to pay for the ophthalmic diagnostic 
imaging provided on June 30, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 24, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you have not been able to get out of bed due to 
being so weak. You have not been able to use your prosthetic leg and need help with doing daily activities and 
you live alone. The Plan denied your request. The Plan says the request is not 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 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 SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee is unable to drive 
themself to dialysis treatment. You also say that the enrollee has no other means of transportation, and is 
dependent on non-emergency transport taxi service to attend treatments three days per week. The Plan denied 
your request. The Plan says the enrollee has exhausted their non-emergent transportation offered by the Plan by 
using 178 one-way trips, far exceeding the allowed 72 one-way trips, and therefore is not eligible for any 
additional rides. 
 
 
 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 up to 72 one-way trips per year.  
 
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. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for occupational therapy provided on May 05, 
2022, to July 27, 2022. 
 
You asked the Plan to waive the copayment for occupational therapy. You say that these services were 
approved so they 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 
$498.42 copayment for Outpatient rehabilitation services. 
 
You have been asked to pay a $498.42 copayment for occupational therapy. 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. You have been asked to pay a total of $498.42 for the thirteen occupational 
therapy visits. Therefore, we decided that the Plan does not have to waive the copayment for occupational 
therapy provided on May 05, 2022, to July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lens fitting (92310) provided on April 26, 2022. 
 
You asked the Plan to pay for contact lens fitting (92310). You say that this is an allowed benefit. You also say 
you are eligible for the $40 reimbursement, and you verified this by calling the Plan. The Plan denied your 
request. The Plan says this service is a covered benefit, but you have exceeded the limits set in the subscriber 
agreement.  
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 once every 2 years. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover contact lenses instead of lenses 
and frames every two years. The record shows that this service was previously provided on April 15, 2021. 
This means that this benefit has been exhausted. Based on this information, we decided that the Plan's rules for 
coverage of contact lens fitting (92310) have not been met. Therefore, we decided that the Plan does not have 
to pay for contact lens fitting (92310) provided on April 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital stay provided from January 31, 2022, to 
February 2, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an inpatient hospital stay. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the enrollee must receive care from 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 inpatient hospital stay provided from January 
31, 2022, to February 2, 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 the cardioversion, elective, electrical conversion of 
arrhythmia; external (92960) provided on November 17, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the physician service. You say that this should be covered. The Plan denied your 
request. The Plan says prior authorization was not obtained before the service was rendered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the 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 cardioversion, elective, electrical conversion of arrhythmia; external 
(92960) provided on November 17, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the 
abdomen. 
 
You asked the Plan to pre-approve an MRI scan. You say that you are appealing the denied MRI scan. The 
Plan denied your request. The Plan says there was no clinical documentation submitted; therefore, the 
authorization for an MRI scan cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
  We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of a magnetic resonance imaging (MRI) 
scan of the abdomen. have been met. There was no medical documentation submitted to prove the medical 
necessity of the MRI scan. Therefore, we decided that the Plan does not have to pre-approve a magnetic 
resonance imaging (MRI) scan of the abdomen.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an immediate family 
member on November 1, 2021. 
 
You asked the Plan to pay for the home health services. You say that you need the services, and your daughter 
spends quite a bit of time caring for you. You also say that you feel your daughter should be compensated, and 
you believe it would be better for the Plan to pay her rather than pay an outside person who would not pay 
close attention to you. The Plan denied your request. The Plan says you obtained homes health services from an 
immediate family member who is not a contracted or licensed home health agency provider without orders, 
authorization or referral from your Primary Care Physician (PCP). The Plan also says that this request for 
reimbursement cannot be approved. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the home health services have not been met. Specifically, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the home 
health services provided by an immediate family member on November 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of a high frequency chest wall oscillation (HFCWO) 
device. 
 
You asked the Plan to pre-approve HFCWO device. You say that this helps prevent pulmonary infections, 
hospitalizations, or the need for antibiotics. The Plan denied your request. The Plan says the enrollee does not 
meet criteria for use of this device. 
 
The Plan follows Medicare rules. Medicare rules state that HFCWO devices are only covered if specific criteria 
are met. 
 
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 HFCWO device. Our reviewer says that 
the enrollee does not meet the criteria for this device. Our physician reviewer found the enrollee has chronic 
obstructive pulmonary disorder (COPD) with dyspnea and difficulty raising secretions. The Volara system 
combines airflow oscillation, nebulization, and positive end-expiratory pressure. There is insufficient evidence 
of benefit int he treatment of COPD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HFCWO device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve use of a high frequency chest wall oscillation (HFCWO) device.