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

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC), group 3 standard, multiple 
power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) and 
accessories (E2359, E1007, E2311, E2620, E2605, E1012, E0955, E1028, E2377, E2313). 
 
You asked the Plan to pre-approve a group 3 power wheelchair with multiple power options. You say that 
appellant argues that your PWC is 13 years old and needs replacement. The Plan denied your request. The Plan 
says this type of PWC is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that you must meet criteria in the Local Coverage 
Determination for coverage of PWC with multiple power options. 
 
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 group 3 power wheelchair with 
multiple power options. Our reviewer says that this item is not medically reasonable and necessary. Our 
physician reviewer found the provided records do not support that you are high risk for skin breakdown, have a 
history of pressure ulcer(s) or have had skin flap surgery. Records do not document that you perform bladder 
self-catheterization and are unable to transfer independently or that you have increased muscle tone or 
spasticity to meet criteria for the power tilt/recline. As the power tilt/recline is not covered, the multiple power 
option is not covered and as the wheelchair base is not covered, the requested accessories are not covered. You 
may meet criteria for a group 3 power wheelchair with no power option. 
 
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 group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (PWC), group 3 standard, 
multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (K0861) 
and accessories (E2359, E1007, E2311, E2620, E2605, E1012, E0955, E1028, E2377, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on September 19, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
September 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient infusion therapy provided from 
January 4, 2022, to May 17, 2022. 
 
You asked the Plan to waive the copayment for infusion therapy. You say that this was a preventative service 
and has been covered in the past. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $275 
copayment for each outpatient surgery provided in an outpatient hospital.  
 
You have been asked to pay a $225.21 copayment for each of the 17 infusion therapy sessions ($225.21 
copayment x 17 sessions = $3828.57 copayment). You have also been asked to pay $110.17 copayment for an 
infusion therapy session provided on May 17, 2022, because the enrollee met their out-of-pocket maximum. 
You have been asked to pay a total of $3939.28 for these services ($3828.57 copayment + $110.17 copayment 
= $3939.28 total copayment). This item/service falls within the outpatient surgery provided in an outpatient hospital 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 outpatient infusion therapy 
provided from January 4, 2022, to May 17, 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 you require more intensive therapy in order to regain 
your independence and stay home safely. The Plan denied your request. The Plan says you do not meet all the 
required Medicare criteria for admission to an inpatient rehabilitation facility. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different 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 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on 
November 10, 2022. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for physician/practitioner services/specialist. 
 
You have been asked to pay a $45 copayment for a specialist office visit. This item/service falls within the 
physician/practitioner services/specialist 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 specialist office visit provided on November 10, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that these services should be 
totally covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $255 
copayment for each Medicare-covered in or out-of-network one-way ambulance trip.  You have been asked to pay a $255 copayment for the ambulance services. This item/service 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 the ambulance 
services provided on September 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the hospital observation services provided 
from September 7, 2022, to September 8, 2022. 
 
You asked the Plan to waive the copayment for the hospital observation services. You say that you think that 
the cost sharing should be lower. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $325 
copayment per visit, for Medicare-covered outpatient hospital observation services. 
 
You have been asked to pay a $325 copayment for the hospital observation services. These items/services fall 
within the outpatient hospital observation 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 the hospital observation services provided from September 7, 2022, to September 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 15, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the records provided support medical 
necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on October 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for labratory services provided on October 20, 2022. 
 
You asked the Plan to pay for labratory services. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for labratory services 
provided on October 20, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for two diagnostic ultrasounds provided on 
December 7, 2022. 
 
You asked the Plan to waive the copayment for ultrasounds. You say that you only had one ultrasound and 
have never had two copays before. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $40 
copayment for each in-network outpatient diagnostic ultrasound.  
 
You have been asked to pay a $80 copayment for two ultrasounds ($40 copayment x 2 services = $80). This 
item/service falls within the in-network outpatient diagnostic ultrasound 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 two diagnostic ultrasounds provided on December 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies provided on August 12, 2022. 
 
You asked the Plan to pay for wound care supplies. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for wound care supplies 
provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the specialist visit provided by an in-
network provider on October 24, 2022. 
 
You asked the Plan to waive the cost sharing for the specialist visit. You say that you think that the cost sharing 
for this service should be lower. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 says that you must pay the full cost for 
most covered services until you have paid the $500 deductible, and the deductible applies to specialist visits. 
Your contract with the Plan also says that you must pay a $10 copayment for in or out-of-network services 
obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physicians 
assistant or other non-physician health care professionals in a specialists office. You have been asked to pay a cost share of $165.28 for the specialist visit ($155.28 deductible + $10 
copayment = $165.28). The item or service you asked the Plan to waive the cost sharing for falls within the 
physician/practitioner services, including doctor's office visits benefit category. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to 
physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that 
had not been met at the time the specialist visit was provided on October 24, 2022. Therefore, we decided that 
the Plan does not have to waive the cost sharing for the specialist visit provided by an in-network provider on 
October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility care provided on January 19, 2022, to 
March 11, 2022. 
 
You asked the Plan to pay for skilled nursing facility care. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
care provided on January 19, 2022, to March 11, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the spinal injection provided on May 12, 
2021, and June 28, 2021. 
 
You asked the Plan to waive the copayment for the injections. You say that you do not agree with the 
copayment applied to these services. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $0 
copayment for any surgical procedures during a colorectal screening, and a $200 copayment for all other 
ambulatory surgical center services. 
 
 
 
 You have been asked to pay a $400 copayment for the injections ($200 x 2 injections = $400). These 
items/services fall within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers 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 the spinal 
injection provided on May 12, 2021, and June 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for group telehealth psychotherapy provided on November 10, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the group telehealth psychotherapy. You say that the services were medically 
necessary. The Plan denied your request. The Plan says unauthorized, out-of-network care is not covered. 
 
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 group telehealth psychotherapy provided on 
November 10, 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 power seat elevation system (E2300) and attendant 
control (E2331). 
 
You asked the Plan to pre-approve a power seat elevation system and attendant control. You say that you are 
requesting the attendant control because the enrollee suffers from right carpel tunnel syndrome, which prevents 
them from operating buttons, gripping, and holding on to things. You also say that the enrollee lives alone, and 
the adjustable seat would allow for safer transfers, bring them up to counter height, access to their freezer, and 
perform activities of daily living. The Plan denied your request. The Plan says the request for these two 
accessories does not meet the requirements for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature. Medicare rules also say if an attendant control (E2331) is 
provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
 
 
 
 We looked at the file and Medicare rules. Specifically, the record shows that the enrollee has been approved for 
an electronic connection between wheelchair controller and 2 or more power systems (E2311), therefore, the 
requested additions are not covered. Based on this information, we decided that Medicare rules for coverage of 
a power seat elevation system and attendant control have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a power seat elevation system (E2300) and attendant control (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for urgent care on August 26, 2022. 
 
You asked the Plan to waive the deductible for urgent care. You say that you want to appeal the amount being 
charged. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to urgently needed services.  
 
The item or service you asked the Plan to waive the deductible for falls within the urgently needed services 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$1,000 deductible which applies to urgently needed services. This cost sharing is a contractual obligation that 
had not been met at the time urgent care was received on August 26, 2022. Therefore, we decided that the Plan 
does not have to waive the deductible for urgent care on August 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an eye appointment to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an eye appointment. You say that the in-network providers rush you and 
you aren't comfortable in their care. The Plan denied your request. The Plan says there was no preauthorization 
by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility, 
and this was not an emergency. Therefore, the decision is upheld. 
 
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 
an eye appointment to be provided by an out-of-network (OON) provider.