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

 
We decided that the Plan does not have to pre-approve home oxygen. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is 
no evidence that the enrollee is in a chronic stable state. 
 The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
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 requested services. Our physician 
reviewer found that the enrollee has severe obesity and obstructive sleep apnea. Some of the records are 
illegible, but there was evidence of hypoxemia on overnight oximetry. The enrollee is not using his positive 
airway pressure (PAP) device during the overnight oximetry. Medicare requires that obstructive sleep apnea be 
adequately treated in order for overnight oximetry to qualify a patient for supplemental oxygen. There is no 
data showing hypoxemia during activity, so criteria for oxygen are not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home oxygen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on October 11, 2021. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says you are responsible for 
all costs for hearing aids not purchased from a Plan hearing network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from a Plan hearing network provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not purchased from a Plan 
hearing network provider. Based on this information, we decided that the Plan's rules for coverage of hearing 
aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on 
October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement Continuous Positive Air Pressure (CPAP) 
machine (E0601, E0562). 
 
You asked the Plan to pre-approve the replacement CPAP machine.. You say that your device has a recall and a 
replacement is needed. The Plan denied your request. The Plan says your current device was issued in 2018 and 
is less than 5 years old. There is no record of irreparable damage. The manufacturer's recall is voluntary and the 
manufacture has offered a repair. 
 
The Plan must follow Medicare rules. Medicare rules say that a device can be replaced during the 5-year 
reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there 
is no requirement for a new clinical evaluation, sleep test, or trial period. 
 
We looked at the file and Medicare rules. The record shows the current CPAP machine is less than 5 years old 
and does not have irreparable damage. Based on this information, we decided that Medicare rules for coverage 
of the replacement CPAP machine. have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a replacement Continuous Positive Air Pressure (CPAP) machine (E0601, E0562).
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 this is medically necessary for the enrollee's 
condition. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's 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 pay for the medical nutrition therapy (CPT code 97803) provided 
from October 30, 2020, through December 10, 2021, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that you are requesting reimbursement of 
services rendered. The Plan denied your request. The Plan says this provider is out-of-network, the services 
were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 medical nutrition therapy (CPT code 97803) 
provided from October 30, 2020, through December 10, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary for your 
therapy. The Plan denied your request. The Plan says this device is statutorily non covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory screening services (CPT code(s): 81430, 
81404, 81407, 81405, 81325) provided on July 13, 2021. 
 
You asked the Plan to pay for the laboratory screening services. You say that the claim should be paid. The 
Plan denied your request. The Plan says these services are not authorized because screening testing is not a 
Medicare benefit.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory screening services, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for the laboratory screening services (CPT code(s): 81430, 81404, 81407, 81405, 81325) provided 
on July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of excess skin of the thigh. 
 
You asked the Plan to pre-approve the removal of excess skin of the thigh. You say that this procedure is 
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this surgery is 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 the removal of excess skin of the thigh. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee has had massive weight loss and 
has excessive skin and lipodystrophy of the thigs. The record does not indicate the presence of intertrigo or 
other functional complications refractory to conservative therapy. The requested procedure appears cosmetic. 
The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, 
of the requested service. 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 the removal of excess skin of the thigh have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the removal of excess skin of the thigh.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bi-level respiratory assist device without back-up rate 
(E0470). 
 
You asked the Plan to pre-approve a bi-level respiratory assist device without back-up rate. You say that the 
item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a and a bi-level respiratory assist device without 
back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a bi-level respiratory assist device 
without back-up rate. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found the documentation indicates that the enrollee does not have Central or Complex Sleep Apnea, nor 
evidence of clinical evaluation through sleep studies and titration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bi-level respiratory assist device without back-up rate have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a bi-level respiratory assist device without 
back-up rate (E0470).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for Removal of Central Venous Access Device 
on December 3, 2021. 
 
You asked the Plan to waive the copayment for surgery. You say that you do not feel this constitutes outpatient 
surgery by any means, there was no surgery done. The Plan denied your request. The Plan says Outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers and the 
copayment you are being charged 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 a $400 
copayment for Removal of Central Venous Access Device.  
 You have been asked to pay a $400 copayment for surgery. Outpatient Surgery falls within the Outpatient 
hospital 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 Removal of Central 
Venous Access Device on December 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
September 11, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that because of an 
emergency you did not have time to request approval for the transportation. The Plan denied your request. The 
Plan says the proper copayment was applied for this service. 
 
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 one-way Medicare-covered ambulance service for ground or air ambulance.  
 
  You have been asked to pay a $150 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance service 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 September 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the excision of skin and subcutaneous tissue for 
hidradenitis provided on November 10, 2021, by an out-of-network provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not 
referred by a network provider, and the services were not urgent or emergent, nor were they 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 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the excision of skin and subcutaneous tissue for hidradenitis provided on November 10, 2021, by an out-of-
network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that it is medically necessary 
to receive a new wheelchair. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
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 power wheelchair that has recently been repaired. This device serves the same 
purpose as a power wheelchair and accessories. There is no evidence presented that your current wheelchair 
has irreparable damage and will not function.  Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair and accessories.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on August 20, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services and contact lenses provided on 
October 28, 2021, and November 1, 2021. 
 
You asked the Plan to pay for the ophthalmological services and contact lenses. The Plan denied your request. 
The Plan says we cover more vision care than what Medicare covers, but you must use a doctor in our vision 
network. 
 
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 services when you use a doctor in the Plans vision network. 
 
We looked at the file and the Plan's rules. The file shows that you did not use a doctor in the Plans vision 
network. Based on this information, we decided that the Plan's rules for coverage of the ophthalmological 
services and contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for 
ophthalmological services and contact lenses provided on October 28, 2021, and November 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on 
May 28, 2021. 
 
You asked the Plan to pay for non-emergency transportation, wheelchair van. The Plan denied your request. 
The Plan says your Plan excludes coverage, under "Exclusions and Limitations", for non-emergency 
ambulance. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on 
May 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 19, 2021. 
 
You asked the Plan to pay for the lab services. You say that you billed these services correctly. The Plan denied 
your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 29, 2020. 
 
You asked the Plan to pay for the physician's services. 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. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on December 28, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services 
provided on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint radiofrequency neurolysis. 
 
You asked the Plan to pre-approve facet joint radiofrequency neurolysis. The Plan denied your request. The 
Plan says the criteria for coverage has not been met. The Plan also says that only one or two levels are allowed 
per session, with three (or four) considered when sufficient medical necessity is documented but no 
documentation has been received. 
 
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 radiofrequency ablations.  Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found that the medical records show that the request is for three spinal levels, 
in contrast to the two levels treated in 2019. More than 2 years have elapsed since the prior treatment and 
repeat diagnostic procedures have not been documented as met. In addition, one or two levels are allowed per 
session, with three (or four) considered when unique circumstances and sufficient medical necessity are 
documented but no such documentation has been received with the appeal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint radiofrequency neurolysis.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for FISH/Cx bladder testing (CPT code 88120) provided on June 
7, 2021. 
 
You asked the Plan to pay for the laboratory service. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not authorized because screening, FISH /Cx bladder testing, billed 
with CPT 88120, is not a Medicare benefit for the diagnosis listed on the claim and is done for screening 
purposes. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for FISH/Cx bladder testing (CPT code 88120) provided on June 7, 2021.