Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist office visit and defibrillator 
device programming provided on February 15, 2022. 
 
You asked the Plan to waive the copayments for the specialist visit and defibrillator programming. You say that 
you should have a $0 copayment for diagnostic tests in a physician's office. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 $15 
copayment for office visits to a specialist. 
 
Your contract with the Plan also clearly says that you must pay a $125 copayment for diagnostic procedures and tests, including ultrasounds. 
 
You have been asked to pay a $15 copayment for the specialist visit. The specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to 
pay $104.11 for the defibrillator programming, which is less than the $125 copayment per the EOC. The 
defibrillator programming falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 
benefit category. The total for all services is $119.11. 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 a 
specialist office visit and defibrillator device programming provided on February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for diabetic shoe inserts and custom molds 
provided on March 24, 2022. 
 
You asked the Plan to waive the deductible for the shoe inserts and custom molds. You say that you were 
informed that you would have a zero balance. The Plan denied your request. The Plan says the correct amount 
was applied to your deductible. 
 
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 $675 deductible which applies to certain items and services.  
 
The shoe inserts and custom molds fall within the Diabetes Self-Management Training, Diabetic Services and 
Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $675 deductible which applies to certain items and services. This cost sharing is a contractual obligation that 
had not been met at the time the shoe inserts and custom molds were received on March 24, 2022. Therefore, 
we decided that the Plan does not have to waive the deductible for diabetic shoe inserts and custom molds 
provided on March 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen contents provided with billed date of 
service July 22, 2021. 
 
You asked the Plan to pay for the portable oxygen contents. You say that this was incorrectly denied. The Plan 
denied your request. The Plan says since payment was made for contents for DOS June 29, 2021, no payment 
can be made for the July DOS as it was less than one month later. 
 
The Plan must follow Medicare rules. Medicare rules say that the DOS used for billing oxygen contents should 
be the anniversary date of the equipment and may not correspond to the date that the contents are delivered. No 
more than one UOS is payable per month. 
 
We looked at the file and Medicare rules. Since payment was made for oxygen contents for DOS June 29, 
2021, the DOS for the next month's contents should be July 29, 2021, regardless of when the contents were 
delivered. Based on this information, we decided that Medicare rules for coverage of the portable oxygen 
contents have not been met. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
contents provided with billed date of service July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a diagnostic eye exam and additional 
testing provided on March 28, 2022. 
 
You asked the Plan to waive the copayments for the eye exam and testing. You say that you do not think there 
should have been a second copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $35 
copayment for services to diagnose and treat diseases and conditions of the eye. 
 
Your contract with the Plan also clearly says that you must pay a $75 copayment for diagnostic procedures and tests. 
 
You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the Vision Care 
benefit category. You have also been asked to pay a $40 total copayment for the additional eye tests, which is 
less than the $75 copayment per the EOC. The additional eye tests fall within the Outpatient Diagnostic Tests 
and Therapeutic Services and Supplies benefit category. The total for all services is $75. 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 a diagnostic eye exam and additional testing provided on March 28, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radionuclide stress testing. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of myocardial 
infarction in June of 2022 with cardiac catheterization and successful angioplasty and stent placement. The 
follow-up visit with the cardiologist showed stable clinical status. There is no evidence provided that would 
support the need for radionuclide stress testing. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radionuclide stress testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on January 
3, 2022. 
 
You asked the Plan to waive the copayment for the eye exam. You say that you should not be charged for the 
routine exam. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
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 $45 
copayment for each eye exam to diagnose and treat diseases and conditions of the eye.  
 
The file shows that the claim was billed as a diagnostic exam. Treatment was discussed for cataracts and dry 
eyes. Therefore, you have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the 
Vision 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 a diagnostic eye exam 
provided on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an oxygen concentrator provided from 
October 8, 2021, to November 8, 2021. 
 
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment (DME) items, including oxygen equipment.  
 You have been asked to pay $19.37, which is 20% of the allowed amount for the oxygen concentrator ($96.83 
allowed amount x 20% coinsurance = $19.37). The oxygen concentrator falls within the Durable Medical 
Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance 
for an oxygen concentrator provided from October 8, 2021, to November 8, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 home health physical therapy visits. 
 
You asked the Plan to pre-approve 16 home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services.  
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 16 home health physical therapy visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee 
primarily requires endurance training, which is not a skilled service. The notes as per section 40.2.1 of chapter 
7 Medicare benefit manual do not indicate a timeline of response indicating additional therapy is needed or that 
the enrollee's condition can be reasonably expected to improve within the the proposed time frame and that the 
services or improvement is dependent upon unique skills of a therapist rather than repetitive exercise. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 16 home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the clinical information provided supports the 
need for SNF care. You say that you are incapable of caring for yourself and cannot be cared for in the home. 
The Plan denied your request. The Plan says the enrollee's needs are custodial and that there is no 
documentation of a need for daily skilled care.  
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 services. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs are custodial and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by the requested  
out-of-network provider. 
 
You asked the Plan to pre-approve physician's services to be provided by the requested out-of-network 
provider. You say that this physician performed a right hip surgery replacement on July 19, 2021 and you were 
advised your left hip would need hip replacement as well. You say that this provider knows your history and 
you trust him. The Plan denied your request. The Plan says this physician is out-of-network and the Plan does 
not cover out-of-network services rendered with the exceptions of the following: Emergency care or urgently 
needed services that you get from an out-of-network provider. If you need medical care that Medicare requires 
our Plan to cover and providers in our network cannot provide this care, you can get this care from an out-of-
network provider. For these types of referrals, you must obtain authorization before seeking care. Your PCP 
can assist you with obtaining authorization. In this situation, we will cover these services as if you got the care 
from a network provider. If you do not have prior authorization before you receive services from an out-of-
network provider, you may have to pay for these services yourself. Renal dialysis services when you are 
temporarily outside the service area, or when prior 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 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on December 9, 2021. 
 
You asked the Plan to pay for infrared therapy. You say that  The Plan denied your request. The Plan says 
infrared therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
infrared therapy devices and any related accessories is not reasonable and necessary under section 
1862(a)(1)(A) of the Social Security Act (the Act). 
 
We looked at the file and Medicare rules. Medicare says say that there is sufficient evidence to conclude the 
use of infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided on December 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve the feature. You say that this is a necessity for home care. The Plan denied 
your request. The Plan says this is 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 power seat elevation feature (E2300).
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 you would like the Plan to reconsider their 
denial. 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 you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR) for the enrollee. 
 You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the patient is already on an anticoagulant and is not on any rhythm control medications. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while the enrollee has a history of atrial fibrillation, there is no documentation provided to suggest a 
history of unexplained syncope, crytogenic stroke, or any apparent other indication for this request. There is 
insufficient documentation to support the medical necessity for insertion of an ILR in the enrollee'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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR) for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiology procedure provided on May 8, 2021. 
 
You asked the Plan to pay for a radiology procedure. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a radiology procedure provided on May 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a neurostimulator. 
 
You asked the Plan to pre-approve insertion of a neurostimulator. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 The Plan follows Medicare rules. Medicare rules say that effective January 1, 2002, sacral nerve stimulation is 
covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
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 insertion of a neurostimulator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found in this case; the 
record indicates that the enrollee has urinary incontinence. The record indicates that the enrollee has diabetes 
and a neurogenic bladder. The record does not indicate that the enrollee is refractory to conventional therapy 
(documented behavioral, pharmacologic and/or surgical corrective therapy). The elements of the coverage 
criteria are not satisfied. The requested service is not 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 insertion of a neurostimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve insertion of a neurostimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an acute rehabilitation admission provided from  
July 25, 2021, to July 29, 2021. 
 
You asked the Plan to pay for the acute rehabilitation admission. The Plan denied your request. The Plan says 
the services did not meet criteria and you did not obtain a prior authorization. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services.  Therefore, we decided that the Plan does not have to pay for an acute rehabilitation admission provided from 
July 25, 2021, to July 29, 2021.