Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 15, 2022. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you feel it should 
be covered since it was a medical necessity. 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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on March 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on January 27, 
2022. 
 
You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are 
non-covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the 
Plan does not have to pay for the CxBladder testing (0012M) provided on January 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99212) provided on February 22, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit (99212) provided on February 
22, 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 assessment of and care planning (99483) provided on 
February 16, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the care planning. You say that it was the responsibility of the assisted living 
facility to obtain prior authorization. The Plan denied your request. The Plan says the services were provided 
out-of-network and were not approved in advance. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the assessment of and care planning (99483) 
provided on February 16, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repairs of current power wheelchair. 
 
You asked the Plan to pre-approve the power wheelchair repairs. You say that the enrollee has limited use of 
his right hand that fits directly on the power chair control. This allows him the freedom of moving his power 
chair throughout the halls. The Plan denied your request. The Plan says the enrollee resides in a SNF therefore, 
repairs are not covered under Medicare. 
 
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 power wheelchair repairs is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve repairs of current power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the out-of-network electrocardiogram you had on March 11, 
2022. 
 
You asked the Plan to pay for the out-of-network electrocardiogram. You say that you were surprised to 
receive this bill because previous services had been paid. The Plan denied your request. The Plan says you had 
exhausted your out-of-network benefit. 
 
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 have a Point of 
Service (POS) benefit that allows you to receive certain services out-of-network at a higher cost sharing.  The 
Plan's annual limit for POS services is $3000. 
 
Records show that you had already exceeded this $3000 maximum for out-of-network services prior to the 
electrocardiogram at issue in this appeal. Your Plan does not cover out-of-network services after this limit is reached. Therefore, we decided that the Plan does not have to pay for the out-of-network electrocardiogram 
you had on March 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automatic blood pressure monitor (A4670). 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that you are appealing the 
denial for the blood pressure cuff. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve the automatic blood pressure monitor 
(A4670).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on March 21, 2021. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were sent by your doctor due to 
the situation being an emergency. 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 $250 
copayment per day for diagnostic radiology services that are not ultrasounds.  
 
You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on March 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient visit (99215) provided on March 23, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit. The Plan denied your request. The Plan says the services 
were provided out-of-network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the outpatient visit (99215) provided on March 23, 
2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rollator walker. 
 
You asked the Plan to pre-approve these services. You say that your walking has gotten worse due to your 
current walker. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker. The requested rollator walker serves the same purpose as your current 
walker. The file shows that your current walker is not more than five years old or irreparably damaged. 
Therefore, we decided that the Plan does not have to pre-approve a rollator walker.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation of nasal valves (30999). 
 
You asked the Plan to pre-approve radiofrequency ablation of nasal valves. You say that you are asking for 
reconsideration of the denial of an office radiofrequency ablation of the septal swell bodies and radiofrequency 
ablation of nasal valve soft tissue and remodeling of cartilage. The Plan denied your request. The Plan says 
there is not enough medical proof that shows the safety and/or success of radiofrequency ablation of nasal 
valves when used for this reason. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation of nasal valves have not been met. Therefore, we decided that the Plan 
does not have to pre-approve radiofrequency ablation of nasal valves (30999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair ramp (E1399). 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that due to the enrollee's medical conditions 
and wheelchair bound status, she will benefit with having a ramp at her house. The Plan denied your request. 
The Plan says this is not a covered benefit. 
 
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 the wheelchair ramp (E1399).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a transthoracic echocardiogram (TTE) 
with doppler (ultrasound) provided on March 10, 2022. 
 
You asked the Plan to reduce the copayment for the ultrasound. You say that you feel the test is non-
radiological and should only be a $20 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 $160 
copayment for radiological diagnostic services, such as ultrasounds.  
 
You have been asked to pay a $160 copayment for the ultrasound. The ultrasound falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and 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 reduce the copayment for a transthoracic echocardiogram (TTE) with doppler (ultrasound) provided on March 10, 
2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
December 20, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed to be 
taken to the hospital following complications during a colonoscopy. 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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance 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 
ambulance transportation provided on December 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) provided on 
December 2, 2021. 
 
You asked the Plan to waive the copayment for the ECG. You say that this should be covered since it was part 
of your annual physical. 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 $0 for an 
annual physical. 
 
Your contract with the Plan also clearly says that you must pay $10 per day for outpatient diagnostic tests, such 
as EKG's. You have been asked to pay a $10 copayment for the ECG. The ECG falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies benefit category. Please note that diagnostic tests and lab services 
are not included under the annual physical. 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 an 
electrocardiogram (ECG) provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor (CGM) and 
supplies (K0553, K0554). 
 You asked the Plan to pre-approve the FreeStyle Libre 14 day. You say that the medical records provided 
support the necessity of the services in dispute The Plan denied your request. The Plan says the enrollee does 
not meet the criteria. Despite multiple attempts to obtain additional clinicals, the supporting clinical 
documentation was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the FreeStyle Libre 14 day have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor 
(CGM) and supplies (K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for a negative pressure wound therapy pump 
provided on January 26, 2022. 
 
You asked the Plan to reduce the coinsurance for the wound therapy pump. You say that you feel the amount 
should be prorated. 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 each durable medical equipment (DME) item.  
 
You have been asked to pay $188.01, which is 20% of the allowed amount for the wound therapy pump 
($940.07 allowed amount x 20% coinsurance = $188.01). The wound therapy pump 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 reduce the 
coinsurance for a negative pressure wound therapy pump provided on January 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's condition requires IRF care. The Plan 
denied your request. The Plan says an intensive rehabilitation program is not medically necessary. 
 
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 based on the medical records provided, the complexity of your nursing, medical 
and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You are at home having been discharged from the acute hospital on 07/12/2022 and on 
outpatient medications with no issues that appear to require a physicians evaluation three or more times per 
week. The documentation does not explain why the intensive inpatient rehabilitation therapy program is 
necessary and why therapy at a lower level of care such as in a skilled nursing facility is not appropriate for 
you. There is no documentation that you require the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. The records do not clarify that treatment at the skilled nursing facility level is 
not appropriate in this case.  
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested service is not supported based on the records received. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia. 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 admission to an inpatient rehabilitation facility (IRF).