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

 
We decided that the Plan does not have to pay for the laboratory services provided on November 17, 2021, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. You say that the specimens were sent to your laboratory 
by the referring provider, and you would like the claim reprocessed for payment. The Plan denied your request. 
The Plan says the rendering and referring providers are both OON providers and there was no approved 
authorization. Also, the service rendered was not urgent or emergent. 
 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 laboratory services provided on November 17, 
2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses provided on November 5, 2021. 
 
You asked the Plan to pay for the eyeglasses. You say that the Plan's vision provider told you that this provider 
was in-network. The Plan denied your request. The Plan says after reviewing the member account, the member 
nor the member representative has called into the Plans vision vendor for provider information, the member 
was not advised by the Plan that this provider was in network. The claim was denied correctly as member does 
not have out of network benefits on this Plan. 
 Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services when provided by a network optical provider. 
 
We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network 
optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on 
November 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat epidural steroid injection (ESI) services. 
 
You asked the Plan to pre-approve the repeat ESI services. You say that you had measurable relief from the 
back pain with the initial epidural injection on May 2, 2022. You say that your physician plans to do a series of 
3 injections. The Plan denied your request. The Plan says the Medicare criteria has not been met for repeat 
injection after 2 weeks. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESIs are covered for certain clinical 
indications. 
 
We looked at the file and Medicare rules. The records show that the previous L4-L5 lumbar epidural steroid 
injection on May 2, 2022, provided measurable pain relief reported at 50%. The records show that the doctor 
plans to repeat the L4-L5 lumbar epidural steroid injection with the same approach, level, and medication. 
Coverage for repeat epidural steroid injections after 14 days is limited to the use of a different approach, level 
and/or medication. Based on this information, we decided that Medicare rules for coverage of the repeat ESI services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat epidural 
steroid injection (ESI) services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance response and treatment without transport (A0998) 
provided on December 24, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment without transport. You say that you were 
not able to go to the hospital due to COVID-19 regulations. The Plan denied your request. The Plan says that 
ambulance services without transportation is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Based on recent guidelines, ambulance services without transportation could be 
covered under certain circumstances. However, no documentation was requested from the ambulance company 
detailing the services that were received. It is the burden of the Plan to determine whether the criteria for 
coverage of ambulance services without transportation were satisfied based on Medicare guidelines. Therefore, 
we decided that the Plan has to pay for the ambulance response and treatment without transport (A0998) 
provided on December 24, 2021.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wrist-hand brace provided on January 4, 
2022. 
 
You asked the Plan to waive the coinsurance for wrist-hand brace. You say that you told the doctor you did not 
want the brace, but the doctor told you to take it anyway because there was no charge. The Plan denied your 
request. The Plan says coinsurance is correct. 
 
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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.  
 
  You have been asked to pay $12.98, which is 20% of the allowed amount for wrist-hand brace. The allowed 
amount is $64.93 (20% x $64.93 = $12.98). Wrist-hand brace falls within the Durable medical equipment 
(DME) and relate 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 wrist-hand 
brace provided on January 4, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that your services were rendered in the hospital setting 
and in good faith that the hospital complied with all authorization requirements. You also say you should not be 
penalized for the hospital's failure to comply with your requirements. The Plan denied your request. The Plan 
says the rendering provider is a non-participating provider, and the referring provider involved in these services 
is a non-participating provider with the plan. The Plan also says that they plan did not authorize any services 
for these providers. 
 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 provided on December 20, 2021, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 15, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the rendering provider is a non-participating provider, and there is no 
referring provider involved in these services. The Plan also says that they did not authorize any services for this 
provider or the facility. 
 
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 provided on December 15, 2021, 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 therapeutic continuous glucose monitor (CGM) 
(K0553). 
 
You asked the Plan to pre-approve a therapeutic CGM. You say that this is medically necessary for managing 
your diabetes. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic 
continuous glucose monitor (CGM) (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acupuncture provided on November 26, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Acupuncture. You say that that you were misinformed about requiring prior 
authorization. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 Acupuncture provided on November 26, 2021 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 continuous glucose monitor (K0553). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the knee orthosis and accessories provided 
on August 30, 2021. 
 
You asked the Plan to waive the cost share for the knee orthosis and accessories. You say that you do not 
believe you should be charged as this equipment did not work correctly. The Plan denied your request. The 
Plan says the coinsurance has processed correctly at this time. 
 
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 10% 
coinsurance for Durable medical equipment.  
 
 
 You have been asked to pay a total cost share of $139.30 for the knee orthosis and accessories ($1392.96 
Medicare approved amount x 10% coinsurance). This equipment falls within the durable medical equipment 
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 cost share for the knee orthosis and accessories 
provided on August 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee requires this level of care. The 
Plan denied your request. The Plan says the enrollee has not met the required criteria for the SNF admission. 
 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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who 
suffered a cardiac arrest with pacemaker placement. From a nursing perspective, the beneficiary received oral 
medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received 
physical, occupational, and speech therapy. The beneficiary was unable to participate in therapy. 
 
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. 
This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a 
skilled nursing facility 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Diagnostic services provided on January 
26, 2022. 
 
You asked the Plan to waive the copayment for Diagnostic services. You say that the copayment amount 
should be $25. The Plan denied your request. The Plan says the claim will be upheld as the cost share of $150 
applied correctly to the claim. 
 
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 $150 
copayment for Diagnostic services.  
 
You have been asked to pay a $150 copayment for Diagnostic services. Diagnostic services 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 Diagnostic services provided on January 26, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that you feel that SNF care is necessary. The 
Plan denied your request. The Plan says this level of care is not required medically. 
 
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 the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating household distances. Daily skilled services are not shown to be required to establish a 
maintenance program or to prevent deterioration of the enrollees condition. The enrollees care needs, 
custodial and intermittent, 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 the SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary due to his respiratory 
condition. The Plan denied your request. The Plan says Medicare criteria for this are not met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not shown to be medically reasonable and necessary. Our physician reviewer found 
the enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), and a pulmonologist's note 
states that spirometry shows severe obstructive disease, although those results and the date are not provided. 
The patient was recently admitted in acute respiratory failure with carbon dioxide retention, likely acute on chronic. He has sleep apnea and severe obesity, and there is likely a component of obesity-hypoventilation 
syndrome. The patient may benefit from bilevel positive airway pressure (BiPAP) during sleep, with the 
average volume assured pressure support (AVAPS) mode. This has not been tried at home. Medicare does not 
cover a ventilator when used as BiPAP.  
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on August 23, 2021, by an 
OON provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration of the 
denied claim. The Plan denied your request. The Plan says the rendering provider is an OON provider and there 
was no referral from an in-network provider or an approved authorization. Also, the service rendered was not 
urgent or emergent. 
 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 services provided on August 23, 
2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on March 31, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the claim processed appropriately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code A0425 and A0427 is not supported in the medical record. Specifically, these codes 
were billed modifier GY, which indicates that the services are not covered. 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 pay for ambulance services provided to the enrollee on March 31, 2021.