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

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
and waive the copayment for the physical therapy services provided from September 9, 2021, to September 22, 
2021. 
 
You asked the Plan to pay for the outpatient services. You say that the medications you received in the hospital 
were denied. You say that these are the normal medications that you take at home. You say that you are not 
allowed to bring your own medications while you are in the hospital. You also say that this should be covered 
as part of your treatment. The Plan denied your request. The Plan says the drugs you received are considered 
self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan says the drugs you received are not covered under Medicare Part B. The Plan also says you pay 
a $10 copayment for physical therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Additionally, your contract with the Plan clearly says that you must pay a $10 copayment for 
outpatient physical therapy services that you receive in network. Therefore, we decided that the Plan does not 
have to pay for the self-administered drugs provided in an outpatient setting and waive the copayment for the 
physical therapy services provided from September 9, 2021, to September 22, 2021.  
 
Benefits for the outpatient services may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on July 22, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you would like reconsideration because you were 
not informed of this requirement. The Plan denied your request. The Plan says hearing aids are not covered 
when purchased out-of-network. 
 
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 the 
preferred brand of hearing aids when they are purchased in-network. 
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Specifically, the records indicate that these hearing 
aids were purchased out-of-network. Per the contract with the Plan, this is not a covered benefit when rendered 
out-of-network. Therefore, we decided that the Plan does not have to pay for hearing aids provided on July 22, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 31, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has been billed with an 
inappropriate place of service. 
 
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 laboratory 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 the laboratory services provided on August 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the stomach area 
with contrast. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no physical exam results that show why this exam is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the scan that been 
requested is with contrast. The plan is correct in the sent that the enrollee has no symptoms, and surveillance 
without contrast would be adequate and safer with regard to renal function. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the stomach area with contrast.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on August 22, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
paramedics assessed that you needed medical attention and taped up your finger. You also say that refused the 
ambulance transport and decided to have a family member transport you to the hospital. The Plan denied your 
request. The Plan says the ambulance charges are not covered because there was no transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 22, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on August 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intermittent urinary catheter, with insertion supplies 
(CPT code A4353) to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the DME. You say that you are asking for an HMO network exception. The 
Plan denied your request. The Plan says there are in-network provider(s) within a reasonable distance from 
your location that can provide this service or item: 
 
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 intermittent urinary catheter, with insertion supplies (CPT code A4353) to be provided by an out-of-
network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in shower. 
 
You asked the Plan to pre-approve a walk-in shower. You say that this is necessary for the enrollee's condition. 
The Plan denied your request. The Plan says this is not covered by Medicare or by the Plan. 
 
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 walk-in shower.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), Qlogic (K0108), 
expandable controller (E2377), harness (E2313), and electronic connection (E2311). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. 
The Plan denied your request. The Plan says the power seat elevation system and Qlogic do not primarily serve 
a medical purpose and the electronic connection, harness, and expandable controller are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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 for the electronic connection, harness, and expandable 
controller.  Our reviewer says that these items are not medically necessary. Our physician reviewer found that 
the patient has only one power option on the approved wheelchair and does not need to control the power options through a joystick. The patient's upper extremity strength and function support that the patient can 
control any power options through their own switches. 
 
We looked at this physician's review, the file, and Medicare rules. The power seat elevation system and Qlogic 
do not serve a purpose that is primarily medical in nature. These items are available to the general public and 
would be helpful even to those who are not sick or injured. The electronic connection, harness, and expandable 
controller are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system (E2300), Qlogic (K0108), expandable controller (E2377), harness (E2313), and 
electronic connection (E2311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pneumatic lumbar traction device to be provided by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says medical studies have not proven that the device(s) is helpful for treatment of their health 
problem. 
 
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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is currently insufficient high quality evidence supporting the use of this treatment being 
effective for the patient's conditions over the long-term or safer and more effective than simpler more active 
modes of traction. Therefore, without sufficient support made for this request, the Zynex Medical pneumatic 
lumbar traction device will be considered not medically necessary. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the pneumatic lumbar traction device to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, 
including programming (CPT code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 service. Our physician reviewer 
found the documentation provided, there is insufficient clinical evidence to support the medical appropriateness 
and necessity of replacing the patients old implantable loop recorder (ILR) with a new ILR. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion, subcutaneous cardiac rhythm monitor, including programming (CPT code 
33285).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to a Long-Term Acute Care Hospital. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. You appear 
to be improving and should only require short-term additional acute care services that can be safely 
administered at the current facility. You do not require services at the LTACH that are not already available at 
the current facility. There are no services at the LTACH that you require that are not already available and 
covered at the current facility. Our physician reviewer found that your condition does not meet Medicare 
criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110), topical application of fluoride 
varnish (D1206), and two resin-based composites (D2392 x2) provided on May 6, 2021, and June 30, 2021. 
 
You asked the Plan to pay for the prophylaxis, topical application of fluoride varnish, and resin-based 
composites. You say that you were not personally informed that these services would not be covered by your 
insurance. You also say that these services were vital to your dental health. The Plan denied your request. The 
Plan says you have exceeded your maximum benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers a $500 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on March 18, 2021 and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the prophylaxis (D1110), topical application of fluoride varnish 
(D1206), and two resin-based composites (D2392 x2) provided on May 6, 2021, and June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on November 9, 2021. 
 You asked the Plan to pay for the eyeglasses. You say that you would like reconsideration because you paid the 
remaining balance out-of-pocket and are not sure why this has been denied. The Plan denied your request. The 
Plan says the benefit allowance has been applied correctly. 
 
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 offers a $250 allowance for eyewear to correct vision. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of any amount above $250 for the eyewear have not been met. Specifically, the record indicates that 
the Plan paid $250 towards the eyeglasses. You are responsible for any amount above $250. Of note, the record 
does not indicate that you are being held liable for an additional amount beyond what you paid out-of-pocket. 
This decision is solely based on the Plan's allowance of $250 towards your eyeglasses. Therefore, we decided 
that the Plan does not have to pay for the eyeglasses purchased on November 9, 2021.
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 enrollee is disabled and can barely walk. 
You say that the enrollee is a danger to herself, is confused, and cannot follow directions. The Plan denied your 
request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the 
enrollee can receive the care needed in another setting. 
 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 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, 
had stable vital signs, and clear lungs. The enrollee received physical therapy, speech therapy, and occupational 
therapy. The enrollee was at a supervision to contact guard assist level with functional mobility, including gait 
to 300 feet. The enrollee required varying assist with activities of daily living. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient physical therapy services 
provided from October 4, 2021, to October 27, 2021. 
 
You asked the Plan to waive the copayments for physical therapy. You say that these services should be 
covered by your inpatient hospital copayment. The Plan denied your request. The Plan says these claims were 
processed correctly, and your copayments were assessed in accordance with your contract. You are responsible 
for a $10 copayment for each Medicare covered physical, occupational, or speech language therapy visit. 
 
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 
copayment for each Medicare-covered physical, occupational, or speech language therapy visit.  
 You have been asked to pay a $10 copayment for each of the seven physical therapy visits. You say that these 
services should be covered by your inpatient hospital copayment; however, we verified with the Plan that you 
were not in the hospital with inpatient status at the time of these services. An inpatient copayment applies only 
to the services provided while you are in the hospital as an inpatient. The therapy services in this case were 
provided on an outpatient basis while you were not admitted to the hospital, and therefore the therapy 
copayments apply. 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 the outpatient physical therapy 
services provided from October 4, 2021, to October 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on April 30, 2021, and May 1, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
speech was slurred, you could not speak to answer questions, and you could not walk. You also say that you 
feel these services should be covered due to the situation you were in. The Plan denied your request. The Plan 
says you refused transport and there is a signed refusal that was witnessed by your wife. The Plan also says that 
Medicare does not cover ambulance services in cases of non-transport. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on April 30, 2021 to May 1, 2021. The ambulance 
benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the 
services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and 
treatment with no transport (A0998) provided on April 30, 2021, and May 1, 2021.